, 2Public health, universal health coverage, and Sustainable Development Goals: can they coexist?.Lancet. 2015; 386: 928-930 by ensuring all people can receive quality health services they need, without experiencing financial hardship. Global agendas and actors have amplified calls for UHC in recent years, driven at least in part by the explicit inclusion of UHC achievement in target 3.8 of the UN Sustainable Development Goals (SDGs)3UNTransforming our world: the 2030 Agenda for Sustainable Development. UN,2015https://sustainabledevelopment.un.org/post2015/transformingourworld/publicationDate accessed: March 25, 2020, 4UN Statistical CommissionSDG indicator 3·8.1 metadata.https://unstats.un.org/sdgs/metadata/files/Metadata-03-08-01.pdfDate: 2018Date accessed: March 25, 2020, 5UN Statistical CommissionSDG indicator 3.8.2 metadata.https://unstats.un.org/sdgs/metadata/files/Metadata-03-08-02.pdfDate: 2019Date accessed: April 22, 2020 and heightened emphasis within recent UN resolutions1UNGAResolution 74/2: political declaration of the high-level meeting on universal health coverage.https://undocs.org/en/A/RES/74/2Date: Oct 18, 2019Date accessed: November 15, 2019 and WHO programmatic objectives (eg, the target of 1 billion more people benefiting from UHC from 2018 to 2023 as part of WHO's Thirteenth General Programme of Work [GPW13]).6WHOThirteenth General Programme of Work 2019–2023: promote health, keep the world safe, serve the vulnerable. World Health Organization,Geneva2019, 7WHOResolution A72/5. Thirteenth General Programme of Work, 2019–2023. WHO Impact Framework. World Health Organization,Geneva2019 Regional and country-driven efforts to elevate UHC on policy agendas have occurred as well, both building upon long established UHC programmes (eg, in Japan,8Universal health coverage for inclusive and sustainable development: lessons from Japan. A World Bank study. World Bank,Washington, DC2014 much of western Europe,9Universal health coverage: a quest for all countries but under threat in some.Value Health. 2013; 16: S39-S45, 10Reforming health care in seven European nations.Health Aff. 1991; 10: 7-21 and many countries in Latin America11Health-system reform and universal health coverage in Latin America.Lancet. 2015; 385: 1230-1247, 12Toward universal health coverage and equity in Latin America and the Caribbean: evidence from selected countries. World Bank,Washington, DC2015) and galvanising newer commitments to UHC implementation (eg, in India, Kenya, and South Africa).13Going universal: how 24 developing countries are implementing universal health coverage from the bottom up. World Bank,Washington, DC2015 To better understand how actions and investments are delivering on the ultimate goal of UHC—improving health outcomes—it is essential to quantify and track trends in effective health service provision, as well as the extent to which advances in service coverage correspond with the potential health gains populations should experience.In 2014, WHO and the World Bank published a UHC measurement framework in which service coverage was defined as a spectrum of services—promotion, prevention, treatment, rehabilitation, and palliation—across the life cycle.14WHOWorld BankMonitoring progress towards universal health coverage at country and global levels: framework, measures, and targets. WHO, World Bank,Geneva; Washington, DC2014, 15Monitoring progress towards universal health coverage at country and global Levels.PLoS Med. 2014; 11e1001731 This framework emphasised the importance of providing services for individuals' health needs throughout their lifespans and quantifying effective coverage of interventions delivered by health systems. Conceptually, effective coverage unites intervention need, use, and quality into a single metric, representing the proportion of health gain that could be potentially received from an intervention relative to what is actually experienced.16Access, utilization, quality, and effective coverage: an integrated conceptual framework and measurement strategy.Soc Sci Med. 2005; 61: 97-109, 17Effective coverage: a metric for monitoring universal health coverage.PLoS Med. 2014; 11e1001730 At the health-system level, effective coverage aims to capture the fraction of total potential health gains actually delivered relative to what a health system could have theoretically delivered.16Access, utilization, quality, and effective coverage: an integrated conceptual framework and measurement strategy.Soc Sci Med. 2005; 61: 97-109 To quantify such population-level health gains, Shengelia and colleagues outlined an approach to measure an aggregate of health-system effective coverage.16Access, utilization, quality, and effective coverage: an integrated conceptual framework and measurement strategy.Soc Sci Med. 2005; 61: 97-109 Effective coverage is a powerful measure: this metric not only demands accountability of intervention availability and use, but also requires that the services received are of sufficient quality to provide the health gains they are supposed to. Yet in practice, effective coverage has to date been rarely measured, particularly across countries and over time. Minimal uptake of effective coverage as a metric for UHC monitoring is at least partly due to data challenges, as most health data systems are not able to capture all three intervention components together (ie, need, use or receipt, and quality) and few data sources can adequately represent these dimensions for conditions involving more complex care (eg, cancer or stroke). Tracer or proxy indicators of effective coverage exist for certain interventions or cause groups (eg, cancers), and recent health-system research by Kruk and colleagues used mortality-to-incidence rates to garner insights into health-care quality in low-income to middle-income countries.18Mortality due to low-quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries.Lancet. 2018; 392: 2203-2212 Nevertheless, to date no multi-country UHC measurement effort to our knowledge has sought to estimate effective coverage across health service domains and population-age groups within a cohesive analytical platform.Following the 2014 WHO/World Bank UHC monitoring framework and SDG adoption in 2015, several multi-country health service coverage indices have been developed to inform UHC measurement.19Monitoring universal health coverage within the Sustainable Development Goals: development and baseline data for an index of essential health services.Lancet Glob Health. 2018; 6: e152-e168, 20WHOWorld BankTracking universal health coverage: 2017 global monitoring report. WHO, World Bank,Geneva; Washington, DC2017, 21WHOPrimary health care on the road to universal health coverage: 2019 monitoring report. World Health Organization,Geneva2019, 22A concise, health service coverage index for monitoring progress towards universal health coverage.BMC Health Serv Res. 2015; 15: 230, 23Assessing Latin America's progress toward achieving universal health coverage.Health Aff. 2015; 34: 1704-1712, 24A comprehensive assessment of universal health coverage in 111 countries: a retrospective observational study.Lancet Glob Health. 2020; 8: e39-e49, 25Measuring progress and projecting attainment on the basis of past trends of the health-related Sustainable Development Goals in 188 countries: an analysis from the Global Burden of Disease Study 2016.Lancet. 2017; 390: 1423-1459, 26Measuring progress from 1990 to 2017 and projecting attainment to 2030 of the health-related Sustainable Development Goals for 195 countries and territories: a systematic analysis for the Global Burden of Disease Study 2017.Lancet. 2018; 392: 2091-2138 Although each effort has shown recognition of prevailing data limitations and challenges with operationalising UHC service coverage across myriad settings,21WHOPrimary health care on the road to universal health coverage: 2019 monitoring report. World Health Organization,Geneva2019, 24A comprehensive assessment of universal health coverage in 111 countries: a retrospective observational study.Lancet Glob Health. 2020; 8: e39-e49 they each have limitations in how well they capture country-level trends and health service needs across the life course.17Effective coverage: a metric for monitoring universal health coverage.PLoS Med. 2014; 11e1001730, 27Monitoring frameworks for universal health coverage: what about high-income countries?.Int J Health Policy Manag. 2019; 8: 387-393, 28Universal health coverage: assessing service coverage and financial protection for all.Am J Public Health. 2016; 106: 1780-1781, 29The LancetEnsuring and measuring universality in UHC.Lancet. 2019; 393: 1, 30Towards a meaningful measure of universal health coverage for the next billion.Lancet Glob Health. 2018; 6: e122-e123, 31Measurement matters: who and what counts on the road to universal health coverage.Lancet Glob Health. 2020; 8: e2-e3 First, current indices primarily rely solely on household survey point estimates from multi-country survey series, which can lead to various measurement limitations (ie, being primarily focused on low-income to middle-income countries; restricted sets of interventions captured; and lags in data availability for understanding trends). Second, most indices include either risk factor indicators (eg, prevalence of non-smoking and non-raised blood pressure in the UHC service coverage index,19Monitoring universal health coverage within the Sustainable Development Goals: development and baseline data for an index of essential health services.Lancet Glob Health. 2018; 6: e152-e168, 20WHOWorld BankTracking universal health coverage: 2017 global monitoring report. WHO, World Bank,Geneva; Washington, DC2017, 21WHOPrimary health care on the road to universal health coverage: 2019 monitoring report. World Health Organization,Geneva2019 the SDG indicator 3.8.14UN Statistical CommissionSDG indicator 3·8.1 metadata.https://unstats.un.org/sdgs/metadata/files/Metadata-03-08-01.pdfDate: 2018Date accessed: March 25, 2020) or health-system inputs or process indicators (eg, health workers per capita and hospital beds per capita in the UHC service coverage index; inpatient admission rates for Wagstaff and colleagues' service coverage index23Assessing Latin America's progress toward achieving universal health coverage.Health Aff. 2015; 34: 1704-1712, 24A comprehensive assessment of universal health coverage in 111 countries: a retrospective observational study.Lancet Glob Health. 2020; 8: e39-e49), or both. The use of such proxy indicators, as well as those influenced by factors outside the health system (eg, tobacco prevalence), for service coverage measurement could misattribute successes in health service provision or misrepresent UHC service coverage. With non-communicable diseases accounting for at least 60% of early death and disability worldwide,32Global, regional, and national disability-adjusted life-years (DALYs) for 359 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017.Lancet. 2018; 392: 1859-1922 the omission of non-communicable disease indicators beyond risk factor prevalence proxies or cancer screening is at odds with the reality of countries' populations and health systems. Third, approaches used to construct overall indices of UHC service coverage typically involve somewhat arbitrary weighting schemes (eg, a series of geometric means4UN Statistical CommissionSDG indicator 3·8.1 metadata.https://unstats.un.org/sdgs/metadata/files/Metadata-03-08-01.pdfDate: 2018Date accessed: March 25, 2020, 19Monitoring universal health coverage within the Sustainable Development Goals: development and baseline data for an index of essential health services.Lancet Glob Health. 2018; 6: e152-e168, 20WHOWorld BankTracking universal health coverage: 2017 global monitoring report. WHO, World Bank,Geneva; Washington, DC2017, 21WHOPrimary health care on the road to universal health coverage: 2019 monitoring report. World Health Organization,Geneva2019 or weighted geometric means23Assessing Latin America's progress toward achieving universal health coverage.Health Aff. 2015; 34: 1704-1712, 24A comprehensive assessment of universal health coverage in 111 countries: a retrospective observational study.Lancet Glob Health. 2020; 8: e39-e49), and thus might not capture the alignment of services provided given a country's health and demographic profile. Last, none of these approaches explicitly accounts for the potential health gains delivered through the health system, a limitation that inhibits our collective understanding of whether or how gains in UHC are improving health outcomes for all.Recent developments from WHO indicate a revived interest in using effective coverage for UHC monitoring; these include the WHO GPW13 Expert Reference Group (ERG) Task Force on Metrics recommendations on effective service coverage measurement33WHO Expert Reference Group on the Draft GPW 13Preliminary report 2018: metrics for the GPW13.https://www.who.int/docs/default-source/documents/about-us/expert-reference-group-preliminary-report.pdf?sfvrsn=27a03101_2Date: May, 2018Date accessed: March 27, 2020 and the WHA72 resolution recommending country pilots on monitoring UHC effective coverage.7WHOResolution A72/5. Thirteenth General Programme of Work, 2019–2023. WHO Impact Framework. World Health Organization,Geneva2019 The GPW13 ERG also supported initial efforts to map health services against population-age groups within a measurement framework and to identify indicator options across the life course in order to estimate UHC effective coverage across countries.33WHO Expert Reference Group on the Draft GPW 13Preliminary report 2018: metrics for the GPW13.https://www.who.int/docs/default-source/documents/about-us/expert-reference-group-preliminary-report.pdf?sfvrsn=27a03101_2Date: May, 2018Date accessed: March 27, 2020 The present analysis contributes to this endeavour through the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, mapping 23 effective coverage indicators across health service types and population-age groups for 204 countries and territories from 1990 to 2019. Based on the construct of health-system effective coverage, we aggregated individual effective coverage indicators to produce an overall index using health gain weights, which were derived from country-specific disease burden estimates relative to theoretical levels of burden avertable given intervention levels and associated effectiveness. We compared the performance of this UHC effective coverage measure against that of previous multi-country UHC service coverage indices21WHOPrimary health care on the road to universal health coverage: 2019 monitoring report. World Health Organization,Geneva2019, 24A comprehensive assessment of universal health coverage in 111 countries: a retrospective observational study.Lancet Glob Health. 2020; 8: e39-e49, 26Measuring progress from 1990 to 2017 and projecting attainment to 2030 of the health-related Sustainable Development Goals for 195 countries and territories: a systematic analysis for the Global Burden of Disease Study 2017.Lancet. 2018; 392: 2091-2138 on a series of validity tests. We then assessed the relationships between pooled health spending per capita and index performance, aiming to capture how close—or how far—countries were in reaching UHC effective coverage frontiers relative to their current spending. Finally, we considered applications of this index for current global and national UHC priorities, such as translating index performance to the number of people covered by effective coverage for the GPW13 UHC billion target.
Additional information about the framework development process and selection of effective coverage indicators can be found in appendix 1 (pp 12–28). UHC=universal health coverage. DALYs=disability-adjusted life-years. MNCH=maternal, neonatal, and child health. DTP3=diphtheria-tetanus-pertussis vaccine, 3 doses. MCV1=measles-containing-vaccine, 1 dose. LRI=lower respiratory infection. MIR=mortality-to-incidence ratio. NCDs=non-communicable diseases. ART=antiretroviral therapy. MPR=mortality-to-prevalence ratio. IHD=ischaemic heart disease. RSDR=risk-standardised death rate. CKD=chronic kidney disease. COPD=chronic obstructive pulmonary disease.As applied in this analysis, the UHC effective coverage measurement framework involves 30 unique cells from a matrix of five health service types—promotion, prevention, treatment, rehabilitation, and palliation—against five population-age groups (reproductive and newborn, children younger than 5 years, children and adolescents aged 5–19 years, adults aged 20–64 years, and older adults aged ≥65 years). Treatment is subdivided into two separate groups: first, communicable diseases and maternal, newborn, and child health; and second, non-communicable diseases. Effective coverage indicators were then mapped to these cells to represent needed health services across the life course.23 effective coverage indicators were included in the present analysis (table 1). As recognised in previous studies,19Monitoring universal health coverage within the Sustainable Development Goals: development and baseline data for an index of essential health services.Lancet Glob Health. 2018; 6: e152-e168, 20WHOWorld BankTracking universal health coverage: 2017 global monitoring report. WHO, World Bank,Geneva; Washington, DC2017, 21WHOPrimary health care on the road to universal health coverage: 2019 monitoring report. World Health Organization,Geneva2019, 22A concise, health service coverage index for monitoring progress towards universal health coverage.BMC Health Serv Res. 2015; 15: 230, 23Assessing Latin America's progress toward achieving universal health coverage.Health Aff. 2015; 34: 1704-1712, 24A comprehensive assessment of universal health coverage in 111 countries: a retrospective observational study.Lancet Glob Health. 2020; 8: e39-e49, 25Measuring progress and projecting attainment on the basis of past trends of the health-related Sustainable Development Goals in 188 countries: an analysis from the Global Burden of Disease Study 2016.Lancet. 2017; 390: 1423-1459, 26Measuring progress from 1990 to 2017 and projecting attainment to 2030 of the health-related Sustainable Development Goals for 195 countries and territories: a systematic analysis for the Global Burden of Disease Study 2017.Lancet. 2018; 392: 2091-2138 data for directly measuring effective intervention coverage are rarely available across health services, locations, and over time. Subsequently, we used viable proxy measures and analytical techniques to approximate effective coverage for conditions considered amenable to health care.40Does healthcare save lives? Avoidable mortality revisited. London School of Hygiene & Tropical Medicine,London2004https://researchonline.lshtm.ac.uk/15535/1/does-healthcare-save-lives-mar04.pdfDate accessed: March 27, 2020, 41Measuring performance on the Healthcare Access and Quality Index for 195 countries and territories and selected subnational locations: a systematic analysis from the Global Burden of Disease Study 2016.Lancet. 2018; 391: 2236-2271, 42Measuring the health of nations: updating an earlier analysis.Health Aff. 2008; 27: 58-71, 43Healthcare Access and Quality Index based on mortality from causes amenable to personal health care in 195 countries and territories, 1990–2015: a novel analysis from the Global Burden of Disease Study 2015.Lancet. 2017; 390: 231-266 Criteria set forth by the WHO ERG guided selection of effective coverage indicators and preferred measurement approaches (appendix 1 pp 12–28).33WHO Expert Reference Group on the Draft GPW 13Preliminary report 2018: metrics for the GPW13.https://www.who.int/docs/default-source/documents/about-us/expert-reference-group-preliminary-report.pdf?sfvrsn=27a03101_2Date: May, 2018Date accessed: March 27, 2020 Such criteria stipulated that effective coverage indicators should be currently measurable (ie, data and methods that support indicator measurement today); reflect differences in effective health services and not factors outside the immediate scope of health systems and UHC (eg, tobacco taxation and physical infrastructure such as roads and water systems); and use indicators already encompassed within the SDGs and GPW13, or draw from data systems required for monitoring of SDGs and GPW13. Several other indicator candidates were considered from 2017 to 2019 (appendix 1 pp 12–28), but inadequate data availability, access, or quality, or a combination of these factors, impeded their inclusion in the current analysis.Four effective coverage indicators were measures of intervention coverage and 19 were mortality-based measures to proxy access to quality of care (table 1; appendix 1 pp 30–32). For the mortality-based measures, we primarily used mortality-to-incidence ratios (MIRs) and mortality-to-prevalence ratios (MPRs) for chronic or longer-term conditions (eg, diabetes or asthma). Without better data on effective coverage, such mortality-based measures are viewed as suitable proxies,33WHO Expert Reference Group on the Draft GPW 13Preliminary report 2018: metrics for the GPW13.https://www.who.int/docs/default-source/documents/about-us/expert-reference-group-preliminary-report.pdf?sfvrsn=27a03101_2Date: May, 2018Date accessed: March 27, 2020, 44Cancer survival in five continents: a worldwide population-based study (CONCORD).Lancet Oncol. 2008; 9: 730-756, 45Cancer survival in Europe 1999–2007 by country and age: results of EUROCARE-5—a population-based study.Lancet Oncol. 2014; 15: 23-34, 46Global surveillance of trends in cancer survival 2000–14 (CONCORD-3): analysis of individual records for 37 513 025 patients diagnosed with one of 18 cancers from 322 population-based registries in 71 countries.Lancet. 2018; 391: 1023-1075 providing good signals on what access to quality care should, at minimum, avert or protect against even if the onset of disease cannot be wholly prevented. The main exception was ischaemic heart disease, for which GBD input data coverage and quality on non-fatal outcomes were less robust than data on causes of death and related risks; subsequently, we used risk-standardised death rates instead of MIRs or MPRs to proxy effective coverage. As a statistical approach used in previous GBD analyses41Measuring performance on the Healthcare Access and Quality Index for 195 countries and territories and selected subnational locations: a systematic analysis from the Global Burden of Disease Study 2016.Lancet. 2018; 391: 2236-2271, 43Healthcare Access and Quality Index based on mortality from causes amenable to personal health care in 195 countries and territories, 1990–2015: a novel analysis from the Global Burden of Disease Study 2015.Lancet. 2017; 390: 231-266 and further described in the appendix 1 (pp 31–32), risk standardisation aims to better isolate variations in mortality associated with health-care access and quality from differences in underlying risk exposures mainly related to factors outside the health system.Effective coverage indicators for intervention coverage were kept on their natural scale (0–100%), whereas the 19 other effective coverage indicators were transformed to values on a 0–100 scale (appendix pp 31–33). Across locations and from 1990 to 2019, 0 was set by values at the 97·5th percentile or higher (ie, “worst” levels of MIRs) and 100 by the 2·5th percentile or lower (ie, “best” levels of MIRs).As outlined by previous work,14WHOWorld BankMonitoring progress towards universal health coverage at country and global levels: framework, measures, and targets. WHO, World Bank,Geneva; Washington, DC2014, 15Monitoring progress towards universal health coverage at country and global Levels.PLoS Med. 2014; 11e1001731, 16Access, utilization, quality, and effective coverage: an integrated conceptual framework and measurement strategy.Soc Sci Med. 2005; 61: 97-109, 17Effective coverage: a metric for monitoring universal health coverage.PLoS Med. 2014; 11e1001730 population-level measures of effective coverage should represent the fraction of total health gains a health system could potentially provide, given currently available interventions, that a health system actually delivers. This construct is thus grounded in the principle of comparability—all health systems ought to maximise potential health gains for their populations—but also requires accounting for local health needs and epidemiological profiles. For instance, if a country currently experiences a high burden of diabetes and a comparatively lower burden of HIV, at least equal or even higher priority in expanding services for diabetes should occur relative to HIV in order to further support health gains.To construct the UHC effective coverage index, we weighted each effective coverage indicator relative to their health gain weights, a metric approximating the population health gains potentially deliverable by health systems for each location-year. More detail is provided in the appendix 1 (pp 32–35), but in brief, calculations were based on three inputs for each effective coverage indicator and corresponding population-age group: estimates on the 0–100 scale, targeted disease burden, and effectiveness categories of associated interventions or services (table 1). For effectiveness, incremental values were assumed by category (ie, 90% effectiveness for category 1, 70% for category 2, 50% for category 3, and so on), as informed by studies published in the Cochrane Database of Systematic Reviews, the Tufts Cost-Effectiveness Analysis Registry and Global Health Cost-Effectiveness Analysis Registry, and Disease Control Priorities, third edition (DCP3); sensitivity analyses on shifting each effective coverage indicator by one category (ie, moving each category 2 indicator up to category 1 and then down to category 3) showed high correlations with current assignments (appendix 1 p 35).As shown in figure 2, UHC effective coverage index estimates based on health gain weighting and an unweighted average across effective coverage indicators were positively associated (r=0·95); however, effects differed across countries.Since no gold-standard measures of UHC service coverage currently exist, we used three types of validity testing to compare UHC effective coverage index performance to previously published multi-country indices of UHC service coverage: the WHO UHC service coverage index for 2017;21WHOPrimary health care on the road to universal health coverage: 2019 monitoring report. World Health Organization,Geneva2019 UHC service coverage index from GBD 2017;26Measuring progress from 1990 to 2017 and projecting attainment to 2030 of the health-related Sustainable Development Goals for 195 countries and territories: a systematic analysis for the Global Burden of Disease Study 2017.Lancet. 2018; 392: 2091-2138 and service coverage index values from the World Bank.24A comprehensive assessment of universal health coverage in 111 countries: a retrospective observational study.Lancet Glob Health. 2020; 8: e39-e49 Further details of these analyses are provided in the appendix 1 (pp 38–52), with results summarised in table 2.Table 2Results for content, known-groups, and construct validity across multi-country health service indices for UHC service coverage measurement
Content validity was evaluated on the basis of the percentage of 30 matrix cells of health service types against population-age groups covered by each index. Known-groups validity was evaluated on the basis of the percentage of 16 country pairs correctly ranked based on country A's UHC or health-system performance being recognised as better than country B's performance; details are found in appendix 1 (pp 45–47). Convergent validity was evaluated on the basis of how much index performance could explain variation in HALE after controlling for levels of sociodemographic development (as measured by SDI). UHC=Universal health coverage. HALE=healthy life expectancy. SDI=Socio-demographic Index. GBD=Global Burden of Diseases, Injuries, and Risk Factors Study. SDGs=UN Sustainable Development Goals.For content validity, we computed the percentage of 30 cells (ie, combinations of health services and population-age groups) from the UHC effective coverage framework that were represented by indicators for each index. For known-groups validity, we assessed how well each index could discriminate between 16 country-pairs for which previous studies show “country A” as having better performance or progress on UHC service coverage than a similar “country B”.11Health-system reform and universal health coverage in Latin America.Lancet. 2015; 385: 1230-1247, 23Assessing Latin America's progress toward achieving universal health coverage.Health Aff. 2015; 34: 1704-1712, 47An assessment of progress towards universal health coverage in Brazil, Russia, India, China, and South Africa (BRICS).Lancet. 2014; 384: 2164-2171, 48Monitoring and evaluating progress towards universal health coverage in Chile.PLoS Med. 2014; 11e1001676, 49Social determinants of health, universal health coverage, and sustainable development: case studies from Latin American countries.Lancet. 2015; 385: 1343-1351, 50Moving towards universal health coverage: lessons from 11 country studies.Lancet. 2016; 387: 811-816, 51Monitoring and evaluating progress towards universal health coverage in Ghana.PLoS Med. 2014; 11e1001691, 52The political path to universal health coverage: power, ideas and community-based health insurance in Rwanda.World Dev. 2018; 106: 87-98, 53Monitoring and evaluating progress towards universal health coverage in Singapore.PLoS Med. 2014; 11e1001695, 54Monitoring and evaluating progress towards universal health coverage in Thailand.PLoS Med. 2014; 11e1001726, 55Achieving universal health coverage: learning from Chile, Japan, Malaysia, and Sweden. Results for Development (R4D).https://www.r4d.org/resources/achieving-universal-health-coverage-learning-chile-japan-malaysia-sweden/Date: 2011Date accessed: March 27, 2020 These pairs were selected a priori, and for each index we calculated the fraction of pairs correctly ordered on the basis of mean estimates and accounting for uncertainty where available. For convergent validity, we quantified how much variation in healthy life expectancy could be explained by each index after removing the average relationship between each index and overall sociodemographic development (as measured by Socio-demographic Index [SDI]). In general, the UHC effective coverage index based on health gain weights showed stronger performance across these three validity measures than previous UHC service coverage measures and the unweighted UHC effective coverage index (table 2; appendix 1 pp 38–52).To better understand potential drivers of UHC effective coverage, we used stochastic frontier metaregression to quantify UHC effective coverage frontiers—estimated maximum levels of UHC effective coverage index achieved given any amount of health spending per capita—and compared country-level UHC effective coverage performance relative to these frontiers. The magnitude of these gaps between the frontier and UHC effective coverage index values provides insights into potential inefficiencies, as well as measurement error, in translating health spending into improved UHC effective coverage at the population level. Further analytical details are in the appendix 1 (pp 53–59).Since UHC aims to minimise financial hardship associated with receiving essential health services, we focused on assessing the relationship between pooled health spending per capita (ie, government spending, prepaid private health spending, and development assistance for health)56Global Burden of Disease Health Financing Collaborator NetworkHealth sector spending and spending on HIV/AIDS, tuberculosis, and malaria, and development assistance for health: progress towards Sustainable Development Goal 3.Lancet. 2020;(published online April 23.)http://doi.org/10.1016/S0140-6736(20)30608-5 and UHC effective coverage performance. Alternative analyses, wherein out-of-pocket spending was included (ie, total health expenditure) and then development assistance for health was excluded (ie, pooled domestic health expenditures), were also done but are not reported here (appendix 2 pp 6–7).Spurred by the GPW13 UHC billion target,6WHOThirteenth General Programme of Work 2019–2023: promote health, keep the world safe, serve the vulnerable. World Health Organization,Geneva2019 which calls for 1 billion more people benefiting from UHC by 2023, various approaches have been considered for translating performance metrics into the number of people covered by health services.20WHOWorld BankTracking universal health coverage: 2017 global monitoring report. WHO, World Bank,Geneva; Washington, DC2017, 21WHOPrimary health care on the road to universal health coverage: 2019 monitoring report. World Health Organization,Geneva2019, 57Service coverage within universal health coverage: how large is the gap? Technical note. World Health Organization,Geneva2017, 58WHOMethods for the 13th General Programme of Work (GPW13) Impact Measurement. Draft for consultation. Version 1.3.1. Jan 30, 2020. World Health Organization,Geneva2020 For this analysis, we used a similar approach currently recommended by WHO:58WHOMethods for the 13th General Programme of Work (GPW13) Impact Measurement. Draft for consultation. Version 1.3.1. Jan 30, 2020. World Health Organization,Geneva2020 we applied index estimates as fractional metrics and multiplied these values by populations to approximate population equivalents with UHC effective coverage.To assess UHC effective coverage trajectories and their contributions towards meeting the UHC 1 billion target, we first projected country-level UHC effective coverage index estimates through to 2023. These projections were based on stochastic frontier metaregression modelled relationships between UHC effective coverage index and total health spending per capita; a related method has been used previously by GBD26Measuring progress from 1990 to 2017 and projecting attainment to 2030 of the health-related Sustainable Development Goals for 195 countries and territories: a systematic analysis for the Global Burden of Disease Study 2017.Lancet. 2018; 392: 2091-2138, 59Trends in future health financing and coverage: future health spending and universal health coverage in 188 countries, 2016–40.Lancet. 2018; 391: 1783-1798 and is described further in the appendix 1 (pp 60–61). Taking UHC effective coverage index as a fraction, we multiplied these values by country-level GBD-based population forecasts through to 2023.60Fertility, mortality, migration, and population scenarios for 195 countries and territories from 2017 to 2100: a forecasting analysis for the Global Burden of Disease Study.Lancet. 2020;(published online July 14.)https://doi.org/10.1016/S0140-6736(20)30677-2 Last, we aggregated these estimates globally and by GBD super-region, and calculated additional population equivalents with UHC effective coverage from 2018 (the GPW13 baseline) to 2023.GBD aims to propagate sources of uncertainty through its estimation process,34
Population equivalents based on taking the UHC effective coverage index as a fraction and multiplying these values by total population for a given location-year to approximate populations covered with UHC effective coverage. UHC=universal health coverage. GBD=Global Burden of Diseases, Injuries, and Risk Factors Study. 95% UI=95% uncertainty interval.* Reported in millions unless otherwise indicated.Pooled public financing is the route to universal health coverage
Methods
Our primary analysis involved three main steps: first, to use intervention coverage or compute proxy measures of effective coverage for 23 indicators; second, to calculate the fraction of potential health gains associated with each effective coverage indicator based on each location's disease burden profile; and third, to construct the overall UHC effective coverage index by weighting each effective coverage indicator relative to its health gains fraction. We then did secondary analyses, assessing UHC effective coverage performance relative to health spending and current trajectories towards the GPW13 UHC billion target. Each step is summarised below and further described in appendix 1 (pp 12–61).This analysis uses estimates from the broader GBD 2019,34GBD 2019 Demographics Collaborators. Global age-sex-specific fertility, mortality, healthy life expectancy (HALE), and population estimates in 204 countries and territories, 1950–2019: a comprehensive demographic analysis for the Global Burden of Disease Study 2019. Lancet (in press).
, 35GBD 2019 Diseases and Injuries Collaborators. Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet (in press).
, 36GBD 2019 Risk Factors Collaborators. Global burden of 87 risk factors in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet (in press).
covering 204 countries and territories from 1990 to 2019. Details of disease-specific, injury-specific, and coverage-specific data inputs and processing, statistical synthesis approaches, and final models are available in the accompanying GBD 2019 capstone publications.34GBD 2019 Demographics Collaborators. Global age-sex-specific fertility, mortality, healthy life expectancy (HALE), and population estimates in 204 countries and territories, 1950–2019: a comprehensive demographic analysis for the Global Burden of Disease Study 2019. Lancet (in press).
, 35GBD 2019 Diseases and Injuries Collaborators. Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet (in press).
, 36GBD 2019 Risk Factors Collaborators. Global burden of 87 risk factors in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet (in press).
This study complies with the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER) statement,37Guidelines for accurate and transparent health estimates reporting: the GATHER statement.Lancet. 2016; 388: e19-e23 with further information provided in the appendix 1 (pp 69–72).Development of the UHC effective coverage measurement framework and selection of effective coverage indicators was based on consultation, methods testing, and refinement via the WHO ERG on the GPW13 from 2017 to 2019;7WHOResolution A72/5. Thirteenth General Programme of Work, 2019–2023. WHO Impact Framework. World Health Organization,Geneva2019, 33WHO Expert Reference Group on the Draft GPW 13Preliminary report 2018: metrics for the GPW13.https://www.who.int/docs/default-source/documents/about-us/expert-reference-group-preliminary-report.pdf?sfvrsn=27a03101_2Date: May, 2018Date accessed: March 27, 2020, 38WHOExpert Reference Group on the Draft GPW 13 Impact Framework 2019–2023.https://www.who.int/about/what-we-do/thirteenth-general-programme-of-work-2019-2023/expert-reference-group-on-the-draft-gpw-13-impact-framework-2019-2023Date accessed: February 25, 2020, 39WHOAn updated method for the essential health services coverage index.https://unstats.un.org/sdgs/files/meetings/webex-17jan2019/1_3.8.1_Tier%20Reclassification%20Request_WHO.pdfDate: Jan 17, 2019Date accessed: March 27, 2020 the background and details of this process are provided in the appendix 1 (pp 12–28). The resulting framework (figure 1) and currently included effective coverage indicators (table 1) sought to represent the range of different health services that populations need across their lifespans while recognising present data gaps and appeals for measurement parsimony (appendix 1 pp 18–28).Table 1Details of the 23 effective coverage indicators included in the UHC effective coverage index, by health service type| Effective coverage indicator | Metric | Effective coverage indicator measurement | Health gain weight inputs | Effectiveness category | ||
|---|---|---|---|---|---|---|
| Numerator | Denominator | |||||
| Reproductive and newborn | ||||||
| Promotion | Met need for family planning with modern contraception | Coverage | Females aged 15–49 years with demand for family planning met with modern contraception | Females aged 15–49 years with demand for family planning | 50% of DALYs due to maternal disorders for females aged 10–54 years | 5 |
| Prevention; treatment, communicable diseases and MNCH | Antenatal, peripartum, and postnatal care for newborn babies | Early neonatal mortality rate | All-cause deaths during the first 7 days of life | Population of early neonates | Early neonatal deaths multiplied by life expectancy at birth (on the basis of theoretical minimum risk life table) | 3 |
| Prevention; treatment, communicable diseases and MNCH | Antenatal, peripartum, and postnatal care for mothers | Maternal mortality ratio | Deaths due to maternal disorders for females aged 10–54 years | Livebirths among females aged 10–54 years | 50% of DALYs due to maternal disorders for females aged 10–54 years | 1 |
| Children younger than 5 years | ||||||
| Prevention | DTP3 vaccine coverage | Coverage | Receipt of three doses of DTP vaccine among children aged 12–23 months | Children aged 12–23 months | DALYs due to diphtheria, tetanus, and pertussis for children younger than 5 years | 1 |
| Prevention | MCV1 coverage | Coverage | Receipt of MCV1 among children aged 12–23 months | Children aged 12–23 months | DALYs due to measles for children younger than 5 years | 1 |
| Treatment, communicable diseases and MNCH | LRI treatment | MIR | Mortality from LRIs for children younger than 5 years | Incidence of LRIs for children younger than 5 years | DALYs due to LRIs for children younger than 5 years | 1 |
| Treatment, communicable diseases and MNCH | Diarrhoea treatment | MIR | Mortality from diarrhoeal diseases for children younger than 5 years | Incidence of diarrhoeal diseases for children younger than 5 years | DALYs due to diarrhoeal diseases for children younger than 5 years | 1 |
| Treatment, NCDs | Acute lymphoid leukaemia treatment | MIR | Mortality from acute lymphoid leukaemia for children aged 1–4 years | Incidence of acute lymphoid leukaemia for children aged 1–4 years | DALYs due to acute lymphoid leukaemia for children aged 1–4 years | 1 |
| Children and adolescents (5–19 years) | ||||||
| Treatment, communicable diseases and MNCH | ART coverage | Coverage | Populations aged 5–19 years living with HIV/AIDS and on ART | Populations aged 5–19 years living with HIV/AIDS | DALYs due to HIV for populations aged 5–19 years | 1 |
| Treatment, NCDs | Acute lymphoid leukaemia treatment | MIR | Mortality from acute lymphoid leukaemia for populations aged 5–19 years | Incidence of acute lymphoid leukaemia for populations aged 5–19 years | DALYs due to acute lymphoid leukaemia for populations 5–19 years | 1 |
| Treatment, NCDs | Asthma treatment | MPR | Mortality from asthma for populations aged 5–19 years | Prevalence of asthma for populations aged 5–19 years | DALYs due to asthma for populations aged 5–19 years | 1 |
| Treatment, NCDs | Epilepsy treatment | MPR | Mortality from epilepsy for populations aged 5–19 years | Prevalence of epilepsy for populations aged 5–19 | DALYs due to epilepsy for populations aged 5–19 years | 3 |
| Treatment, NCDs | Appendicitis treatment | MIR | Mortality from appendicitis for populations aged 5–19 years | Incidence of appendicitis for populations aged 5–19 years | DALYs due to appendicitis for populations aged 5–19 years | 1 |
| Treatment, NCDs | Paralytic ileus and intestinal obstruction treatment | MIR | Mortality from paralytic ileus and intestinal obstruction for populations aged 5–19 years | Incidence of paralytic ileus and intestinal obstruction for populations aged 5–19 years | DALYs due to paralytic ileus and intestinal obstruction for populations aged 5–19 years | 1 |
| Adults (20–64 years) | ||||||
| Treatment, communicable diseases and MNCH | ART coverage | Coverage | Population aged 20–64 years living with HIV/AIDS and on ART | Population aged 20–64 years living with HIV/AIDS | DALYs due to HIV for populations aged 20–64 years | 1 |
| Treatment, communicable diseases and MNCH | Tuberculosis treatment | MIR | Mortality from tuberculosis for populations aged 20–64 years | Incidence of tuberculosis for populations aged 20–64 years | DALYs due to tuberculosis for populations aged 20–64 years | 1 |
| Treatment, NCDs | Diabetes treatment | MPR | Mortality from diabetes for populations aged 20–64 years | Prevalence of diabetes for populations aged 20–64 years | DALYs due to diabetes for populations aged 20–64 years | 3 |
| Treatment, NCDs | IHD treatment | RSDR | Risk-standardised deaths from IHD for populations aged 20–64 years | Population aged 20–64 years | DALYs due to IHD for populations aged 20–64 years | 2 |
| Treatment, NCDs | Stroke treatment | MIR | Mortality from stroke for populations aged 20–64 years | Incidence of stroke for populations aged 20–64 years | DALYs due to stroke for populations aged 20–64 years | 2 |
| Treatment, NCDs | CKD treatment | MPR | Mortality from CKD for populations aged 20–64 years | Incidence of CKD for populations aged 20–64 years | DALYs due to CKD for populations aged 20–64 years | 1 |
| Treatment, NCDs | COPD treatment | MPR | Mortality from COPD for populations aged 20–64 years | Prevalence of COPD for populations aged 20–64 years | DALYs due to COPD for populations aged 20–64 years | 3 |
| Treatment, NCDs | Cervical cancer treatment | MIR | Mortality from cervical cancer for females aged 20–64 years | Incidence of cervical cancer for females aged 20–64 years | DALYs due to cervical cancer for females aged 20–64 years | 1 |
| Treatment, NCDs | Breast cancer treatment | MIR | Mortality from breast cancer for females aged 20–64 years | Incidence of breast cancer for females aged 20–64 years | DALYs due to breast cancer for females aged 20–64 years | 1 |
| Treatment, NCDs | Uterine cancer treatment | MIR | Mortality from uterine cancer for females aged 20–64 years | Incidence of uterine cancer for females aged 20–64 years | DALYs due to uterine cancer for females aged 20–64 years | 1 |
| Treatment, NCDs | Colon/rectum cancer treatment | MIR | Mortality from colon/rectum cancer for populations aged 20–64 years | Incidence of colon/rectum for populations aged 20–64 years | DALYs due to colon/rectum cancer for populations aged 20–64 years | 1 |
| Treatment, NCDs | Epilepsy treatment | MPR | Mortality from epilepsy for populations aged 20–64 years | Prevalence of epilepsy for populations aged 20–64 years | DALYs due to epilepsy for populations aged 20–64 years | 3 |
| Treatment, NCDs | Appendicitis treatment | MIR | Mortality from appendicitis for populations aged 20–64 years | Incidence of appendicitis for populations aged 20–64 years | DALYs due to appendicitis for populations aged 20–64 years | 1 |
| Treatment, NCDs | Paralytic ileus and intestinal obstruction treatment | MIR | Mortality from paralytic ileus and intestinal obstruction for populations aged 20–64 years | Incidence of paralytic ileus and intestinal obstruction for populations aged 20–64 years | DALYs due to paralytic ileus and intestinal obstruction for populations aged 20–64 years | 1 |
| Older adults (≥65 years) | ||||||
| Treatment, communicable diseases and MNCH | ART coverage | Coverage | Population aged ≥65 years living with HIV/AIDS and on ART | Population aged ≥65 years living with HIV/AIDS | DALYs due to HIV for populations aged ≥65 years | 2 |
| Treatment, communicable diseases and MNCH | Tuberculosis treatment | MIR | Mortality from tuberculosis for populations aged ≥65 years | Incidence of tuberculosis for populations aged ≥65 years | DALYs due to tuberculosis for populations aged ≥65 years | 2 |
| Treatment, NCDs | Diabetes treatment | MPR | Mortality from diabetes for populations aged ≥65 years | Prevalence of diabetes for populations aged ≥65 years | DALYs due to diabetes for populations aged ≥65 years | 4 |
| Treatment, NCDs | IHD treatment | RSDR | Risk-standardised deaths from IHD for populations aged ≥65 years | Population aged ≥65 years | DALYs due to IHD for populations aged ≥65 years | 3 |
| Treatment, NCDs | Stroke treatment | MIR | Mortality from stroke for populations aged ≥65 years | Incidence of stroke for populations aged ≥65 years | DALYs due to stroke for populations aged ≥65 years | 3 |
| Treatment, NCDs | CKD treatment | MPR | Mortality from CKD for populations aged ≥65 years | Incidence of CKD for populations aged ≥65 years | DALYs due to CKD for populations aged ≥65 years | 2 |
| Treatment, NCDs | COPD treatment | MPR | Mortality from COPD for populations aged ≥65 years | Prevalence of COPD for populations aged ≥65 years | DALYs due to COPD for populations aged ≥65 years | 4 |
| Treatment, NCDs | Cervical cancer treatment | MIR | Mortality from cervical cancer for females aged ≥65 years | Incidence of cervical cancer for females aged ≥65 years | DALYs due to cervical cancer for females aged ≥65 years | 2 |
| Treatment, NCDs | Breast cancer treatment | MIR | Mortality from breast cancer for females aged ≥65 years | Incidence of breast cancer for females aged ≥65 years | DALYs due to breast cancer for females aged ≥65 years | 2 |
| Treatment, NCDs | Uterine cancer treatment | MIR | Mortality from uterine cancer for females aged ≥65 years | Incidence of uterine cancer for females aged ≥65 years | DALYs due to uterine cancer for females aged ≥65 years | 2 |
| Treatment, NCDs | Colon/rectum cancer treatment | MIR | Mortality from colon/rectum cancer for populations aged ≥65 years | Incidence of colon/rectum cancer for populations aged ≥65 years | DALYs due to colon/rectum cancer for populations aged ≥65 years | 2 |
| Treatment, NCDs | Epilepsy treatment | MPR | Mortality from epilepsy for populations aged ≥65 years | Prevalence of epilepsy for populations aged ≥65 years | DALYs due to epilepsy for populations aged ≥65 years | 4 |
| Treatment, NCDs | Appendicitis treatment | MIR | Mortality from appendicitis for populations aged ≥65 years | Incidence of appendicitis for populations aged ≥65 years | DALYs due to appendicitis for populations aged ≥65 years | 2 |
| Treatment, NCDs | Paralytic ileus and intestinal obstruction treatment | MIR | Mortality from paralytic ileus and intestinal obstruction for populations aged ≥65 years | Incidence of paralytic ileus and intestinal obstruction for populations aged ≥65 years | DALYs due to paralytic ileus and intestinal obstruction for populations aged ≥65 years | 2 |
| Source | Content validity (proportion of cells covered) | Known-groups validity (proportion of 16 country pairs) | Convergent validity (variation of HALE explained, accounting for SDI) | ||||
|---|---|---|---|---|---|---|---|
| Based on mean values | With uncertainty | Beta coefficient | Standard error | R2 | |||
| UHC effective coverage index, health gains weighted (reported 2019) | GBD 2019 | 40% | 94% | 63% | 5·00 | 1·72 | 0·073 |
| UHC effective coverage index, unweighted average (reported 2019) | GBD 2019 | 40% | 94% | 56% | 4·19 | 1·49 | 0·068 |
| UHC service coverage index for SDGs (reported 2017) | GBD 2017 | 33% | 94% | 69% | 4·30 | 1·76 | 0·053 |
| UHC service coverage index for SDG indicator 3.8.1 (reported 2017) | WHO 2019 | 20% | 75% | .. | 4·21 | 1·88 | 0·044 |
| Service coverage index (for most recent year reported) | World Bank 2020 | 17% | 56% | .. | 1·24 | 1·18 | 0·010 |
GBD 2019 Demographics Collaborators. Global age-sex-specific fertility, mortality, healthy life expectancy (HALE), and population estimates in 204 countries and territories, 1950–2019: a comprehensive demographic analysis for the Global Burden of Disease Study 2019. Lancet (in press).
, 35GBD 2019 Diseases and Injuries Collaborators. Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet (in press).
, 36GBD 2019 Risk Factors Collaborators. Global burden of 87 risk factors in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet (in press).
resulting in 1000 draws from the posterior distribution for each measure by location, age, sex, and year. We incorporated uncertainty quantified for each effective coverage indicator and associated disease burden based on GBD 2019 estimates, and did scaling, index construction, and UHC effective coverage index projections at the draw-level to reflect uncertainty. We report 95% uncertainty intervals (95% UIs) based on the ordinal 25th and 975th draws for each measure.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.Results
In 2019, UHC effective coverage performance showed some strong geographical patterns (figure 3), but sizeable heterogeneities also emerged. Various European countries, including Iceland, as well as Australia, Canada, Japan, Singapore, and South Korea, comprised the highest decile, followed by a more geographically diverse group in the ninth decile (eg, Costa Rica, Israel, New Zealand, Portugal, and the USA). Sub-Saharan Africa had among the widest range of UHC effective coverage performances in 2019, with two countries ranking in the sixth decile (Rwanda and South Africa) and 11 countries in the first decile; the countries in the first decile were mainly in western or central sub-Saharan Africa, but also spanned the continent (eg, Angola, Lesotho, Madagascar, and Somalia). Outside of sub-Saharan Africa, ten countries, including Afghanistan, Haiti, Pakistan, and Papua New Guinea, were also in the lowest decile in 2019. In east, southeast, and south Asia, countries largely fell between the eighth (China and Thailand) and second deciles (Laos), with India and Indonesia occupying the third decile. Within Latin America, various countries scored in the eighth or seventh deciles (eg, Chile, Colombia, Peru, and Brazil) but others saw UHC effective coverage index values within the fourth to fifth deciles (eg, Bolivia, Guatemala, and Nicaragua).Performance on the overall UHC effective coverage index often corresponded with levels achieved across individual effective coverage indicators (figure 4); for instance, countries with effective coverage index values of 85 or higher generally had the vast majority of effective coverage indicators exceeding 80. Although high-performing locations usually had lower values for at least some subsets of indicators (eg, met need for family planning or antiretroviral therapy coverage), such indicators often represented areas of lower potential health gains—especially relative to effective coverage indicators proxying health services or interventions for conditions with higher potential health gains in these countries (eg, cardiovascular diseases, cancers, and diabetes). Countries and territories with fairly low overall UHC effective coverage index performance in 2019 (ie, <40) scored similarly low across most effective coverage indicators, although vaccine coverage and proxies for lower respiratory infection and diarrhoea treatment were among the main exceptions.Many countries with middle-range performance on UHC effective coverage (ie, about 45–70) in 2019 had a mixture of fairly high values on most indicators for communicable diseases and reproductive, neonatal, maternal, and child health but comparatively lower scores on many non-communicable diseases, likely mirroring their variable epidemiological profiles and thus populations' health needs. For some countries, especially those in sub-Saharan Africa (eg, Namibia, Rwanda, and Kenya), communicable diseases (eg, HIV) and reproductive, neonatal, maternal, and child health still ranked among indicators with highest potential health gains in 2019, even though non-communicable diseases such as cardiovascular diseases and diabetes are on the rise.35GBD 2019 Diseases and Injuries Collaborators. Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet (in press).
With their fairly high levels of coverage or services proxied by effective coverage indicators for communicable diseases and for reproductive, neonatal, maternal, and child health, several of these countries had higher UHC effective coverage index performance under a health gains weighting approach than under the assumption that each effective coverage indicator could deliver equal health gains to populations across different settings (figure 2). By contrast, in many other countries—especially those in Latin America, central and eastern Europe, and Oceania—non-communicable diseases accounted for a greater proportion of potential health gains by 2019; consequently, these countries' relatively poor performances on several effective coverage indicators proxying non-communicable disease services underpinned lower overall UHC effective coverage index values. High levels of vaccine coverage and performance on effective coverage indicators such as maternal care still contributed to UHC effective coverage performance for such countries; however, these health areas generally represented a smaller fraction of population-level health gains than many non-communicable diseases in these settings. Health gain weights, by country and territory, for each effective coverage indicator are available in the appendix 2 (pp 11–13) and via online data tools.Since 1990, UHC effective coverage performance improved, albeit at variable rates of progress over time and across GBD super-regions (figure 5). The global average increased from 45·8 (95% UI 44·2–47·5) in 1990 to 60·3 (58·7–61·9) in 2019, while the absolute range in performance essentially remained the same (ie, 73·0-point difference in 1990 vs 74·0-point difference in 2019). By 2019, the UHC effective coverage index spanned from 95 or higher in Japan (96·3 [95·0–97·4]) and Iceland (95·3 [93·6–96·8]) to lower than 25 in the Central African Republic (22·3 [16·3–29·3]) and Somalia (23·9 [17·1–31·1]; appendix 2 pp 14–20). Globally, the pace of progress on UHC effective coverage was somewhat slower, albeit not significantly, from 2010 to 2019 (0·9% [0·6–1·2] annualised increase) than from 1990 to 2010 (1·0% [0·8–1·1] annualised increase). Similarly, at the global level, annualised rates of change for population equivalents with effective coverage were slightly lower from 2010 to 2019 (2·0% [1·7–2·3]) than from 1990 to 2010 (2·3% [2·2–2·4]), although this difference was not significant. However, some of these patterns diverged by GBD super-region (figure 5), as well as at the country level (appendix 2, pp 14–20). For instance, in sub-Saharan Africa, UHC effective coverage index performance improved at an average of 2·6% (1·9–3·3) per year from 2010 to 2019, surpassing its annualised rate of change from 1990 to 2010 (1·3% [1·0–1·7] average increase per year). Central Europe, eastern Europe, and central Asia also had significantly faster progress from 2010 to 2019 (1·4% [0·8–1·8] average annual increase) than from 1990 to 2010 (0·5% [0·4–0·6] annual increase).Country-level performance on UHC effective coverage widely varied across different levels of pooled health spending per capita (figure 6), highlighting how increased health spending is necessary but insufficient on its own to improve UHC effective coverage. Overall, the UHC effective coverage index was associated with pooled health spending per capita (r=0·79), but this relationship was varied at different levels of spending. Up to about $2500 (US$, adjusted for purchasing power parity) in pooled health spending per capita, increasingly higher expenditures generally paralleled higher performance on UHC effective coverage index; beyond that, higher expenditures did not correspond as consistently with further improvements in UHC effective coverage performance.The UHC effective coverage frontier charts the highest UHC effective coverage performances, as achieved by countries in 2019, across different levels of pooled health spending per capita (figure 6); in other words, this frontier represents the relative efficiency—or inefficiency—with which countries could translate their health spending into improved UHC effective coverage. Countries including South Korea, Cyprus, Costa Rica, Peru, and Rwanda were among those setting this performance frontier at their corresponding levels of pooled health expenditure per capita. Conversely, countries across the sociodemographic spectrum (ie, Central African Republic, Lesotho, Turkmenistan, Saudi Arabia, and the USA) showed large gaps between their estimated UHC effective coverage index performances in 2019 and what could have been achievable on the UHC effective coverage frontier given these countries' levels of pooled health spending. To reach a UHC effective coverage index of at least 80, under maximum efficiency, countries would need to reach US$1398 in pooled health spending per capita (per year). Equivalent analyses and figures for total health expenditure per capita (ie, pooled health spending plus out-of-pocket spending) and pooled domestic health expenditure per capita (ie, pooled health spending minus development assistance for health) are provided in appendix 2 (pp 6–7).Based on current projections, an estimated 5·0 billion (95% UI 4·8–5·1) population equivalents would have UHC effective coverage in 2023 (table 3). This would translate to 388·9 million (358·6–421·3) more population equivalents with UHC effective coverage over the five-year GPW13 evaluation period (2019–23, with 2018 as the baseline), or the equivalent of adding an average of 77·8 million (71·7–84·3) population equivalents per year during this time. From 2018 to 2023, sub-Saharan Africa was estimated to contribute the most additional population equivalents with UHC effective coverage (ie, 94·5 million [83·6–104·8]). By 2023, an estimated 3·1 billion (3·0–3·2) population equivalents would not have UHC effective coverage, with nearly a third residing in south Asia (ie, an estimated 968·1 million [903·5–1040·3]).Table 3Projected UHC effective coverage performance in 2023 and additional population equivalents with UHC effective coverage from 2018 to 2023, globally and by GBD super-region| UHC effective coverage index (95% UIs) | Population equivalents with UHC effective coverage (95% UI)*Reported in millions unless otherwise indicated. | ||||
|---|---|---|---|---|---|
| 2018 | 2023 | Added from 2018–23 | Covered in 2023 | Not covered in 2023 | |
| Global | 59·8 (58·3 to 61·3) | 61·7 (60·1 to 63·3) | 388·9 (358·6 to 421·3) | 5·0 billion (4·8 to 5·1) | 3·1 billion (3·0 to 3·2) |
| Central Europe, eastern Europe, and central Asia | 63·2 (61·0 to 65·5) | 65·2 (62·7 to 67·6) | 9·1 (7·5 to 10·9) | 273·0 (262·5 to 282·8) | 145·5 (135·7 to 156·1) |
| High income | 85·8 (84·3 to 87·1) | 87·1 (85·5 to 88·5) | 31·6 (28·8 to 34·3) | 958·3 (940·7 to 972·8) | 141·5 (127·0 to 159·1) |
| Latin America and Caribbean | 63·2 (61·1 to 65·1) | 65·6 (63·3 to 67·8) | 33·6 (30·8 to 36·5) | 398·5 (384·7 to 412·0) | 209·0 (195·6 to 222·8) |
| North Africa and Middle East | 60·0 (57·9 to 61·9) | 61·9 (59·6 to 64·0) | 43·0 (39·8 to 45·9) | 402·3 (387·6 to 416·1) | 247·8 (233·9 to 262·5) |
| South Asia | 46·0 (42·6 to 49·2) | 48·4 (44·6 to 51·9) | 88·9 (73·5 to 102·8) | 909·4 (837·2 to 974·0) | 968·1 (903·5 to 1040·3) |
| Southeast Asia, east Asia, and Oceania | 64·2 (60·7 to 67·6) | 66·9 (63·0 to 70·5) | 88·2 (74·4 to 102·8) | 1·5 billion (1·4 to 1·5) | 726·3 (647·9 to 811·6) |
| Sub-Saharan Africa | 43·9 (41·4 to 46·5) | 46·2 (43·3 to 49·1) | 94·5 (83·6 to 104·8) | 555·6 (521·1 to 590·1) | 647·1 (612·7 to 681·7) |
Discussion
The present study offers a new approach to monitoring progress on UHC service coverage: measuring country-level effective coverage and thus better representing how well health systems are delivering health gains relative to their populations' health needs. Amid global advances on the UHC effective coverage index since 1990, our findings show a gap of more than 70 points between locations with the highest and lowest levels of UHC effective coverage remained in 2019. Particularly among low-middle to middle-SDI countries, performance of effective coverage indicators for non-communicable diseases was far lower than levels reached for several communicable diseases and maternal and child health indicators—a pattern suggesting that many countries' health systems and financing priorities are not moving as quickly as their epidemiological and demographic transitions. Higher pooled health spending per capita generally corresponded with higher UHC effective coverage. Nonetheless, country-level performance varied widely and many countries fell well below levels achieved by other countries with similar amounts of health expenditures, emphasising the importance of increasing both health-system efficiencies and funding for UHC. To achieve at least 80 on the UHC effective coverage index, countries would need to reach $1398 pooled spending per capita—and do so under maximum efficiency. An estimated 388·9 million more population equivalents would have UHC effective coverage between 2018 and 2023, falling well short of the GPW13 target of 1 billion more people benefiting from UHC during this time. Genuinely advancing toward UHC requires prioritising—and thus monitoring—effective coverage and health systems' capacities for improving outcomes for all people throughout the world.By 2019, UHC effective coverage improved substantially for many countries, and for some countries the pace of progress has accelerated since 2010. This was particularly evident in sub-Saharan Africa; this GBD super-region nearly doubled its average annual improvements from 2010 to 2019 compared to 1990–2010. Such gains could be related to heightened funding—and thus prioritisation—for HIV, vaccines and childhood infectious diseases, and maternal health during the Millennium Development Goal (MDG) era.61Past, present, and future of global health financing: a review of development assistance, government, out-of-pocket, and other private spending on health for 195 countries, 1995–2050.Lancet. 2019; 393: 2233-2260, 62Development assistance for health: past trends, associations, and the future of international financial flows for health.Lancet. 2016; 387: 2536-2544 As further illustrated by the UHC effective coverage frontier, up to about $2500 per capita, rising levels of UHC effective coverage index generally paralleled pooled health spending; this trend highlights the important role of increasing funding for UHC to jumpstart progress, particularly for countries that still have very low UHC effective coverage in 2019. Yet even at the frontier, reaching better UHC effective coverage performance requires much higher pooled health spending per year: an estimated $1398 per capita to reach 80, and then $2538 per capita to reach 90 and $3424 per capita to reach 95. At present, the only countries achieving 90 or higher on the UHC effective coverage index and such levels of pooled health spending per capita are within the high-income GBD super-region. Substantially increasing total health spending could be one avenue for elevating UHC effective coverage performance; however, many countries still have high out-of-pocket spending relative to their total spending,56Global Burden of Disease Health Financing Collaborator NetworkHealth sector spending and spending on HIV/AIDS, tuberculosis, and malaria, and development assistance for health: progress towards Sustainable Development Goal 3.Lancet. 2020;(published online April 23.)http://doi.org/10.1016/S0140-6736(20)30608-5, 61Past, present, and future of global health financing: a review of development assistance, government, out-of-pocket, and other private spending on health for 195 countries, 1995–2050.Lancet. 2019; 393: 2233-2260 which is strongly related to household catastrophic health expenditures and directly counter to improving financial risk protection within UHC. Focusing on domestic heath spending while also elevating efficiency could be another viable route; our results show that many countries would theoretically achieve much higher UHC effective coverage if they could better translate current amounts of pooled spending per capita into improved performance. How to best address such inefficiencies will markedly vary across contexts, and will require accounting for country-level differences in health-system orientations and structures, political stability and governance systems, and distribution of health resources among populations. Further examination of approaches used by countries near or at the UHC effective coverage frontier relative to their pooled health spending (eg, Rwanda, Peru, South Korea, and Costa Rica) might help identify tractable policy pathways to improved efficiency.Poor performance on various non-communicable diseases has severely hindered progress on UHC effective coverage in many countries—a trend that is likely to only worsen until quality health services for non-communicable diseases are better prioritised by countries and development partners alike. Especially among low-middle SDI to middle-SDI countries, earlier advances on UHC effective coverage were mainly propelled by improving health services focused on communicable diseases, child health, and maternal care. As cardiovascular disease, diabetes, cancers, and other non-communicable diseases became leading causes of early death and disability, they also emerged as population health needs with the highest potential health gains—that is, where health systems could increasingly deliver the most improved outcomes via effective coverage of interventions and services. Re-orienting countries' health systems towards providing effective health services for non-communicable disease is not trivial, especially if their prior focus (and funding) had a more limited scope for the types of services provided, equipment used, and health workforce training required. However, continued inaction also has likely costs: if health systems remain too focused on health problems of the past, and fail to effectively respond to where the largest potential health gains exist today, it can be increasingly difficult to translate current levels of health spending into improved UHC effective coverage. For instance, only a few high-SDI countries (eg, Japan, Switzerland, and South Korea) averaged non-communicable disease performance equal to or higher than effective coverage indicators focused on communicable diseases and maternal and child health by 2019.63GBD 2019 Viewpoint Collaborators. Five insights from the Global Burden of Disease Study 2019. Lancet (in press).
Unless deliberate efforts are taken now to recalibrate health-system and funding priorities, the ability to alter current trajectories for UHC effective coverage could diminish.To catalyse faster gains in the SDG era, WHO's GPW13 set forth its bold billion targets,6WHOThirteenth General Programme of Work 2019–2023: promote health, keep the world safe, serve the vulnerable. World Health Organization,Geneva2019 with the UHC target calling for 1 billion more people benefiting from UHC by 2023, relative to 2018. Current projections have the world falling well short of this ambition, with an estimated 388·9 million (358·6–421·3) more population equivalents having UHC effective coverage by 2023. Even these estimates are likely to be optimistic, as they do not account for trends in financial risk protection—the other key dimension of UHC—nor do they explicitly account for populations' needs for multiple health services. Nonetheless, this initial assessment offers important considerations for the remaining years of GPW13 and then through to 2030. With more than 3 billion population equivalents estimated to lack UHC effective coverage in 2023, targeting populous regions or countries that currently have low UHC effective coverage and investing in service expansion could be one option to accelerating future progress. For instance, south Asia, in combination with southeast Asia, east Asia, and Oceania, was estimated to have nearly 1·7 billion population equivalents without UHC effective coverage in 2023. However, on the basis of current levels of health spending, many countries in these regions already fell below their potential UHC effective coverage performance in 2019. For most countries, heightened health spending alone is unlikely to deliver on ambitious UHC targets; rather, a combination of improving alignment of health systems with population health needs and bolstering efficiencies is likely to chart faster and perhaps more sustained gains.Our measurement framework is grounded in the construct of effective coverage at the health-system level,16Access, utilization, quality, and effective coverage: an integrated conceptual framework and measurement strategy.Soc Sci Med. 2005; 61: 97-109 aiming to represent a country's ability to improve health outcomes in accordance with the health needs and disease burden of its population. From this perspective, effective coverage should capture the fraction of potential population-level health gains actually delivered by the health system, relative to what the health system could have provided at maximum performance of current interventions or services. As such, we used health gain weights to construct the overall UHC effective coverage index and to more heavily weight effective coverage indicators for which a given country's health could produce greater health gains through available interventions. By contrast, the unweighted average of effective coverage indicators implies equal potential health gains irrespective of a country's epidemiological profile or effectiveness of the associated interventions or services, or a combination of both. Equally weighting interventions and their potential for improving health is directly counter to the reality of UHC programmes, which are subject to each country's unique health-system structures, political demands, and health priorities. To capture what can—or should—be achievable through health systems' provision of effective services, we believe the health gains weighting approach can better track country-led UHC investments and policy implementation. Going forward, assessments of UHC effective coverage should strive to apply this method beyond the national level, aiming to capture inequalities in potential health gains not only by location but also within population-age groups, by sex, and across other important sociodemographic dimensions (eg, race/ethnicity and migrant status).Routinely measuring UHC effective coverage requires the existence and maintenance of several functional data systems. Many, if not most, indicators or data systems, or both, that are needed to measure effective coverage indicators are already encompassed within the health-related SDGs, which UN member states have committed to monitoring. These include functional vital registration systems that accurately record causes of death; periodic household surveys that include biomarker data and information on intervention coverage; and disease incidence registries based on administrative systems and notifications for specific causes (eg, cancers and kidney disease).64Monitoring the health-related Sustainable Development Goals: lessons learned and recommendations for improved measurement.Lancet. 2019; 395: 240-246 Deliberate investments by national governments, as well as international agencies where appropriate, are important for strengthening these data systems and identifying how they can be used together to monitor trends in effective coverage.The UHC effective coverage index and corresponding UHC effective coverage measurement framework represent important steps towards capturing a range of needed health services across the life course; nonetheless, as underscored by its multi-year development process (appendix 1 pp 6–21), considerable gaps persist between the breadth of the original candidate effective coverage indicators and those used in the present analysis. Minimal data on rehabilitative services and palliation across countries and over time hindered their direct inclusion or the use of suitable proxy effective coverage indicators. Recent steps by WHO (ie, publishing its first world report on vision65WHOWorld report on vision. World Health Organization,Geneva2019 and upcoming report on hearing,66WHOWorld report on hearing.http://www.who.int/deafness/world-report-hearing/en/Date: 2020Date accessed: May 27, 2020 and its GPW13 indicator on oral morphine availability6WHOThirteenth General Programme of Work 2019–2023: promote health, keep the world safe, serve the vulnerable. World Health Organization,Geneva2019) suggest that data collection for these areas could be increasingly prioritised. A similar paucity of routinely collected data on mental health services and substance use disorder interventions precluded their use in the current UHC effective coverage index. In the future, triangulation of data sources including administrative records, health facility records, and community-based surveys might inform such measurements.67Estimating the coverage of mental health programmes: a systematic review.Int J Epidemiol. 2014; 43: 341-353 Effective coverage indicators on emergency services and trauma care were also considered but ultimately excluded because of data limitations and ongoing methodological challenges (ie, appropriately isolating improvements in effective health services from advances in transportation safety).For non-communicable diseases, we relied on outcome-based effective coverage indicators, preferring to approximate access to quality non-communicable disease care through measures such as MIRs rather than assuming that risk exposure, screening rates, or health-system inputs, or a combination of these factors, can appropriately capture effective service provision for non-communicable diseases. Many national data systems already collect data on cause-specific mortality and disease incidence or prevalence, and when analysed together they should reflect variations in access to and quality of health services and serve as good proxy measures amid imperfect data realities for non-communicable disease services. Conversely, using indicators such as non-tobacco use and non-elevated blood pressure4UN Statistical CommissionSDG indicator 3·8.1 metadata.https://unstats.un.org/sdgs/metadata/files/Metadata-03-08-01.pdfDate: 2018Date accessed: March 25, 2020, 19Monitoring universal health coverage within the Sustainable Development Goals: development and baseline data for an index of essential health services.Lancet Glob Health. 2018; 6: e152-e168, 21WHOPrimary health care on the road to universal health coverage: 2019 monitoring report. World Health Organization,Geneva2019 or inpatient admission rates pushes the world further away from understanding improved outcomes delivered by health systems and effective service provision. If, or when, the quantity and quality of data for measuring health services for non-communicable diseases improve, we would prefer to use more direct measures of effective coverage over outcome-based proxy indicators. For instance, our ideal effective coverage indicator for diabetes treatment would be the proportion of people with diabetes on treatment and meeting specified treatment targets such as glycated haemoglobin lower than 8%. Household surveys such as the WHO STEPwise approach to surveillance (STEPS) are increasingly collecting these data, and time series estimates by location and population-age group could be easily derived if sufficient access to such microdata is possible.In sum, the indicators included in the present study are not meant to be prescriptive; rather, our primary objective was to establish a robust, comparable measurement framework from which UHC effective coverage could be assessed across settings and inform efforts to incorporate effective coverage into UHC monitoring. Continuing to advance effective coverage measurement of UHC in the future, especially if the main alternative is adhering to past measures with known drawbacks and narrow operationalisations of health services for all populations, is strongly supported by the broader GBD study and its collaborators.Our study is subject to limitations beyond those already described. First, this analysis draws from GBD 2019 estimates of outcomes, intervention coverage, and SDG indicators,34GBD 2019 Demographics Collaborators. Global age-sex-specific fertility, mortality, healthy life expectancy (HALE), and population estimates in 204 countries and territories, 1950–2019: a comprehensive demographic analysis for the Global Burden of Disease Study 2019. Lancet (in press).
, 35GBD 2019 Diseases and Injuries Collaborators. Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet (in press).
, 36GBD 2019 Risk Factors Collaborators. Global burden of 87 risk factors in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet (in press).
and thus broader GBD 2019 limitations also apply to the present study (eg, availability and quality of vital registration data, model coherence between cause-specific mortality and non-fatal measures, and new modelling approaches for risk factors and related outcomes). In the case of ischaemic heart disease, for example, new data on the interplay of household air pollution, blood pressure, and ischaemic heart disease mortality resulted in implausible risk-standardised death rates for many low-SDI to low-middle SDI countries when we only accounted for joint exposures to metabolic risks considered amenable to health care.41Measuring performance on the Healthcare Access and Quality Index for 195 countries and territories and selected subnational locations: a systematic analysis from the Global Burden of Disease Study 2016.Lancet. 2018; 391: 2236-2271, 43Healthcare Access and Quality Index based on mortality from causes amenable to personal health care in 195 countries and territories, 1990–2015: a novel analysis from the Global Burden of Disease Study 2015.Lancet. 2017; 390: 231-266 We thus included household and outdoor air pollution in risk standardisation and plan to further examine these risk mediation pathways in the future.Second, health gain weights were based on classifying intervention sets into five effectiveness categories, as informed by published literature provided by Cochrane, the Tufts Cost-Effectiveness Analysis Registry, and DCP3.For some effective coverage indicators, especially treatment of more chronic conditions, distilling a wide range of reported effectiveness on available interventions into a summary assessment was quite difficult. Sensitivity analyses based on shifting each indicator's categorisation up and down one group showed similar overall UHC effective coverage index values (appendix 1 p 35). Formally simulating the range of effectiveness across interventions and incorporating this uncertainty into health gains weighting is an important future avenue for measurement of the UHC effective coverage index.Third, due to limited data quantity or quality (or both), we could not include several original candidates for effective coverage indicators (appendix 1 pp 12–28), including seven expressly recommended by the GPW13 ERG: HPV vaccination, hepatitis C treatment, effective management of hypertension and diabetes, cataract surgery, refractive error correction, and dental care.33WHO Expert Reference Group on the Draft GPW 13Preliminary report 2018: metrics for the GPW13.https://www.who.int/docs/default-source/documents/about-us/expert-reference-group-preliminary-report.pdf?sfvrsn=27a03101_2Date: May, 2018Date accessed: March 27, 2020 As data availability improves alongside methods for estimating these indicators across countries, we plan to test the inclusion of these indicators, and thus some country-level UHC effective coverage index values and rankings might change. Since data are generally more easily available for better-funded interventions and health areas, it is possible that our current estimates of UHC effective coverage are overly optimistic.Fourth, we excluded several effective coverage indicators for which high potential health gains could only be achieved in select locations because of local exposures (ie, malaria and neglected tropical diseases) or current introduction status (eg, pneumococcal conjugate vaccine [PCV]). Subsequently, our results might under-estimate UHC effective coverage in some locations (eg, countries with high coverage of effective malaria interventions) or over-estimate performance in others (eg, countries that have a high pneumonia burden but have yet to introduce PCV). Additional methodological testing is needed to better incorporate these locally relevant intervention needs within a global measurement framework.Fifth, we did not explicitly account for the effects of potential community-level interventions and their contribution to potential health gains (eg, herd immunity garnered from very high coverage of MCV1 or DTP3). Future work should consider whether or how such effects can be incorporated into this measurement framework, particularly given the toll of recent measles outbreaks worldwide.68WHOMeasles—global situation.http://www.who.int/csr/don/26-november-2019-measles-global_situation/en/Date: Nov 27, 2019Date accessed: March 3, 2020Sixth, results of our known-groups validity testing might have varied if more or different country-pairs were selected (appendix 1 pp 45–47). Showing performance based on country means and uncertainty underscores the need to further strengthen data collection and overarching measurement for UHC effective coverage at the country level. Furthermore, it stresses the importance of estimating and reporting uncertainty in monitoring UHC, a limitation of current WHO and World Bank service coverage indices.Seventh, approximating populations with UHC effective coverage by assuming the UHC effective coverage index as a fractional metric and multiplying by population does not account for multimorbidities, nor does it represent the distribution of needed services received within a given population. Measuring UHC effective coverage at increasing granularity (ie, subnational locations and by disaggregated age groups or sex, or both) could help improve our understanding of the distribution of health services within a given population.This study provides a new measurement framework and metric on UHC effective coverage, supporting country and global stakeholders in their efforts to track improved performance over time. By striving to capture potential health gains delivered by health systems, we hope to better diagnose and address challenges that otherwise impede the ultimate objective of UHC: improving health for all people and leaving no one behind. If current trends hold, the world will fall short of delivering on its UHC ambitions for the GPW13 and SDGs. Although this outcome is not yet inevitable, the window for meaningful action and health-system changes is rapidly narrowing. By focusing on UHC effective coverage and populations' health needs across the lifespan, we strengthen the evidence base for bringing UHC closer to reality for all.ContributorsPlease see appendix 1 for more detailed information about individual authors' contributions to the research, divided into the following categories: managing the estimation process; writing the first draft of the manuscript; providing data or critical feedback on data sources; developing methods or computational machinery; applying analytical methods to produce estimates; providing critical feedback on methods or results; drafting the work or revising it critically for important intellectual content; extracting, cleaning, or cataloguing data; designing or coding figures and tables; and managing the overall research enterprise.GBD 2019 Universal Health Coverage CollaboratorsRafael Lozano, Nancy Fullman, John Everett Mumford, Megan Knight, Celine M Barthelemy, Cristiana Abbafati, Hedayat Abbastabar, Foad Abd-Allah, Mohammad Abdollahi, Aidin Abedi, Hassan Abolhassani, Akine Eshete Abosetugn, Lucas Guimarães Abreu, Michael R M Abrigo, Abdulaziz Khalid Abu Haimed, Abdelrahman I Abushouk, Maryam Adabi, Oladimeji M Adebayo, Victor Adekanmbi, Jaimie D Adelson, Olatunji O Adetokunboh, Davoud Adham, Shailesh M Advani, Ashkan Afshin, Gina Agarwal, Pradyumna Agasthi, Seyed Mohammad Kazem Aghamir, Anurag Agrawal, Tauseef Ahmad, Rufus Olusola Akinyemi, Fares Alahdab, Ziyad Al-Aly, Khurshid Alam, Samuel B Albertson, Yihun Mulugeta Alemu, Robert Kaba Alhassan, Muhammad Ali, Saqib Ali, Vahid Alipour, Syed Mohamed Aljunid, François Alla, Majid Abdulrahman Hamad Almadi, Ali Almasi, Amir Almasi-Hashiani, Nihad A Almasri, Hesham M Al-Mekhlafi, Abdulaziz M Almulhim, Jordi Alonso, Rajaa M Al-Raddadi, Khalid A Altirkawi, Nelson Alvis-Guzman, Nelson J Alvis-Zakzuk, Saeed Amini, Mostafa Amini-Rarani, Fatemeh Amiri, Arianna Maever L Amit, Dickson A Amugsi, Robert Ancuceanu, Deanna Anderlini, Catalina Liliana Andrei, Sofia Androudi, Fereshteh Ansari, Alireza Ansari-Moghaddam, Carl Abelardo T Antonio, Catherine M Antony, Ernoiz Antriyandarti, Davood Anvari, Razique Anwer, Jalal Arabloo, Morteza Arab-Zozani, Aleksandr Y Aravkin, Olatunde Aremu, Johan Ärnlöv, Malke Asaad, Mehran Asadi-Aliabadi, Ali A Asadi-Pooya, Charlie Ashbaugh, Seyyed Shamsadin Athari, Maha Moh'd Wahbi Atout, Marcel Ausloos, Leticia Avila-Burgos, Beatriz Paulina Ayala Quintanilla, Getinet Ayano, Martin Amogre Ayanore, Getie Lake Aynalem, Yared Asmare Aynalem, Muluken Altaye Ayza, Samad Azari, Peter S Azzopardi, Darshan B B, Ebrahim Babaee, Ashish D Badiye, Mohammad Amin Bahrami, Atif Amin Baig, Mohammad Hossein Bakhshaei, Ahad Bakhtiari, Shankar M Bakkannavar, Arun Balachandran, Shelly Balassyano, Maciej Banach, Srikanta K Banerjee, Palash Chandra Banik, Agegnehu Bante Bante, Simachew Animen Bante, Suzanne Lyn Barker-Collo, Till Winfried Bärnighausen, Lope H Barrero, Quique Bassat, Sanjay Basu, Bernhard T Baune, Mohsen Bayati, Bayisa Abdissa Baye, Neeraj Bedi, Ettore Beghi, Masoud Behzadifar, Tariku Tesfaye Tesfaye Bekuma, Michelle L Bell, Isabela M Bensenor, Adam E Berman, Eduardo Bernabe, Robert S Bernstein, Akshaya Srikanth Bhagavathula, Dinesh Bhandari, Pankaj Bhardwaj, Anusha Ganapati Bhat, Krittika Bhattacharyya, Suraj Bhattarai, Zulfiqar A Bhutta, Ali Bijani, Boris Bikbov, Ver Bilano, Antonio Biondi, Binyam Minuye Birihane, Moses John Bockarie, Somayeh Bohlouli, Hunduma Amensisa Bojia, Srinivasa Rao Rao Bolla, Archith Boloor, Oliver J Brady, Dejana Braithwaite, Paul Svitil Briant, Andrew M Briggs, Nikolay Ivanovich Briko, Sharath Burugina Nagaraja, Reinhard Busse, Zahid A Butt, Florentino Luciano Caetano dos Santos, Lucero Cahuana-Hurtado, Luis Alberto Cámera, Rosario Cárdenas, Giulia Carreras, Juan J Carrero, Felix Carvalho, Joao Mauricio Castaldelli-Maia, Carlos A Castañeda-Orjuela, Giulio Castelpietra, Franz Castro, Ferrán Catalá-López, Kate Causey, Christopher R Cederroth, Kelly M Cercy, Ester Cerin, Joht Singh Chandan, Angela Y Chang, Jaykaran Charan, Vijay Kumar Chattu, Sarika Chaturvedi, Ken Lee Chin, Daniel Youngwhan Cho, Jee-Young Jasmine Choi, Hanne Christensen, Dinh-Toi Chu, Michael T Chung, Liliana G Ciobanu, Massimo Cirillo, Haley Comfort, Kelly Compton, Paolo Angelo Cortesi, Vera Marisa Costa, Ewerton Cousin, Saad M A Dahlawi, Giovanni Damiani, Lalit Dandona, Rakhi Dandona, Jiregna Darega Gela, Aso Mohammad Darwesh, Ahmad Daryani, Aditya Prasad Dash, Gail Davey, Claudio Alberto Dávila-Cervantes, Kairat Davletov, Jan-Walter De Neve, Edgar Denova-Gutiérrez, Kebede Deribe, Nikolaos Dervenis, Rupak Desai, Samath Dhamminda Dharmaratne, Govinda Prasad Dhungana, Mostafa Dianatinasab, Diana Dias da Silva, Daniel Diaz, Ilse N Dippenaar, Hoa Thi Do, Fariba Dorostkar, Leila Doshmangir, Bruce B Duncan, Andre Rodrigues Duraes, Arielle Wilder Eagan, David Edvardsson, Iman El Sayed, Maha El Tantawi, Islam Y Elgendy, Iqbal RF Elyazar, Khalil Eskandari, Sharareh Eskandarieh, Saman Esmaeilnejad, Alireza Esteghamati, Oluchi Ezekannagha, Tamer Farag, Mohammad Farahmand, Emerito Jose A Faraon, Carla Sofia e Sá Farinha, Andrea Farioli, Pawan Sirwan Faris, Andre Faro, Mehdi Fazlzadeh, Valery L Feigin, Eduarda Fernandes, Pietro Ferrara, Garumma Tolu Feyissa, Irina Filip, Florian Fischer, James L Fisher, Luisa Sorio Flor, Nataliya A Foigt, Morenike Oluwatoyin Folayan, Artem Alekseevich Fomenkov, Masoud Foroutan, Joel Msafiri Francis, Weijia Fu, Takeshi Fukumoto, João M Furtado, Mohamed M Gad, Abhay Motiramji Gaidhane, Emmanuela Gakidou, Natalie C Galles, Silvano Gallus, William M Gardner, Biniyam Sahiledengle Geberemariyam, Abiyu Mekonnen Gebrehiwot, Gebreamlak Gebremedhn Gebremeskel, Leake G Gebremeskel, Hailay Abrha Gesesew, Keyghobad Ghadiri, Mansour Ghafourifard, Ahmad Ghashghaee, Nermin Ghith, Asadollah Gholamian, Syed Amir Gilani, Paramjit Singh Gill, Tiffany K Gill, Themba G Ginindza, Mojgan Gitimoghaddam, Giorgia Giussani, Mustefa Glagn, Elena V Gnedovskaya, Myron Anthony Godinho, Salime Goharinezhad, Sameer Vali Gopalani, Amir Hossein Goudarzian, Bárbara Niegia Garcia Goulart, Mohammed Ibrahim Mohialdeen Gubari, Rafael Alves Guimarães, Rashid Abdi Guled, Teklemariam Gultie, Yuming Guo, Rahul Gupta, Rajeev Gupta, Nima Hafezi-Nejad, Abdul Hafiz, Teklehaimanot Gereziher Haile, Randah R Hamadeh, Sajid Hameed, Samer Hamidi, Chieh Han, Hannah Han, Demelash Woldeyohannes Handiso, Asif Hanif, Graeme J Hankey, Josep Maria Haro, Ahmed I Hasaballah, Md. Mehedi Hasan, Abdiwahab Hashi, Amr Hassan, Shoaib Hassan, Soheil Hassanipour, Hadi Hassankhani, Rasmus J Havmoeller, Simon I Hay, Khezar Hayat, Golnaz Heidari, Reza Heidari-Soureshjani, Delia Hendrie, Claudiu Herteliu, Thomas R Hird, Hung Chak Ho, Michael K Hole, Ramesh Holla, Praveen Hoogar, Kathleen Pillsbury Hopf, Nobuyuki Horita, Naznin Hossain, Mostafa Hosseini, Mehdi Hosseinzadeh, Mihaela Hostiuc, Sorin Hostiuc, Mowafa Househ, Vivian Chia-rong Hsieh, Guoqing Hu, Tanvir M Huda, Ayesha Humayun, Bing-Fang Hwang, Ivo Iavicoli, Segun Emmanuel Ibitoye, Nayu Ikeda, Olayinka Stephen Ilesanmi, Irena M Ilic, Milena D Ilic, Leeberk Raja Inbaraj, Usman Iqbal, Seyed Sina Naghibi Irvani, Caleb Mackay Salpeter Irvine, M Mofizul Islam, Sheikh Mohammed Shariful Islam, Farhad Islami, Hiroyasu Iso, Chidozie C D Iwu, Chinwe Juliana Iwu, Jalil Jaafari, Farhad Jadidi-Niaragh, Morteza Jafarinia, Deepa Jahagirdar, Mohammad Ali Jahani, Nader Jahanmehr, Mihajlo Jakovljevic, Hosna Janjani, Tahereh Javaheri, Achala Upendra Jayatilleke, Ensiyeh Jenabi, Ravi Prakash Jha, Vivekanand Jha, John S Ji, Peng Jia, Yetunde O John-Akinola, Jost B Jonas, Farahnaz Joukar, Jacek Jerzy Jozwiak, Mikk Jürisson, Zubair Kabir, Leila R Kalankesh, Rohollah Kalhor, Aruna M Kamath, Tanuj Kanchan, Neeti Kapoor, Behzad Karami Matin, Marina Karanikolos, Seyed M. Karimi, Nicholas J Kassebaum, Srinivasa Vittal Katikireddi, Gbenga A Kayode, Peter Njenga Keiyoro, Yousef Saleh Khader, Mohammad Khammarnia, Ejaz Ahmad Khan, Maseer Khan, Young-Ho Khang, Khaled Khatab, Amir M Khater, Mona M Khater, Mahalaqua Nazli Khatib, Maryam Khayamzadeh, Jagdish Khubchandani, Neda Kianipour, Young-Eun Kim, Yun Jin Kim, Ruth W Kimokoti, Yohannes Kinfu, Adnan Kisa, Katarzyna Kissimova-Skarbek, Mika Kivimäki, Cameron J Kneib, Jonathan M Kocarnik, Sonali Kochhar, Stefan Kohler, Jacek A Kopec, Anna V Korotkova, Vladimir Andreevich Korshunov, Soewarta Kosen, Anirudh Kotlo, Parvaiz A Koul, Ai Koyanagi, Kewal Krishan, Kris J Krohn, Nuworza Kugbey, Vaman Kulkarni, G Anil Kumar, Manasi Kumar, Nithin Kumar, Om P Kurmi, Dian Kusuma, Hmwe Hmwe Kyu, Carlo La Vecchia, Ben Lacey, Dharmesh Kumar Lal, Ratilal Lalloo, Iván Landires, Van Charles Lansingh, Anders O Larsson, Savita Lasrado, Kathryn Mei-Ming Lau, Paolo Lauriola, Jeffrey V Lazarus, Jorge R Ledesma, Paul H Lee, Shaun Wen Huey Lee, Andrew T Leever, Kate E LeGrand, James Leigh, Matilde Leonardi, Shanshan Li, Lee-Ling Lim, Stephen S Lim, Xuefeng Liu, Giancarlo Logroscino, Alan D Lopez, Platon D Lopukhov, Paulo A Lotufo, Alton Lu, Jianing Ma, Mohammed Madadin, Phetole Walter Mahasha, Morteza Mahmoudi, Azeem Majeed, Jeadran N Malagón-Rojas, Shokofeh Maleki, Deborah Carvalho Malta, Borhan Mansouri, Mohammad Ali Mansournia, Santi Martini, Francisco Rogerlândio Martins-Melo, Ira Martopullo, Benjamin Ballard Massenburg, Claudia I Mastrogiacomo, Manu Raj Mathur, Colm McAlinden, Martin McKee, Carlo Eduardo Medina-Solís, Birhanu Geta Meharie, Man Mohan Mehndiratta, Entezar Mehrabi Nasab, Fereshteh Mehri, Ravi Mehrotra, Teferi Mekonnen, Addisu Melese, Peter T N Memiah, Walter Mendoza, Ritesh G Menezes, George A Mensah, Atte Meretoja, Tuomo J Meretoja, Tomislav Mestrovic, Bartosz Miazgowski, Irmina Maria Michalek, Erkin M Mirrakhimov, Maryam Mirzaei, Mehdi Mirzaei-Alavijeh, Philip B Mitchell, Babak Moazen, Masoud Moghadaszadeh, Efat Mohamadi, Dara K Mohammad, Yousef Mohammad, Naser Mohammad Gholi Mezerji, Abdollah Mohammadian-Hafshejani, Jemal Abdu Mohammed, Shafiu Mohammed, Ali H Mokdad, Lorenzo Monasta, Stefania Mondello, Masoud Moradi, Maziar Moradi-Lakeh, Rahmatollah Moradzadeh, Paula Moraga, Joana Morgado-da-Costa, Shane Douglas Morrison, Abbas Mosapour, Jonathan F Mosser, Amin Mousavi Khaneghah, Moses K Muriithi, Ghulam Mustafa, Ashraf F Nabhan, Mehdi Naderi, Ahamarshan Jayaraman Nagarajan, Mohsen Naghavi, Behshad Naghshtabrizi, Mukhammad David Naimzada, Vinay Nangia, Jobert Richie Nansseu, Vinod C Nayak, Javad Nazari, Rawlance Ndejjo, Ionut Negoi, Ruxandra Irina Negoi, Subas Neupane, Kiirithio N Ngari, Georges Nguefack-Tsague, Josephine W Ngunjiri, Cuong Tat Nguyen, Diep Ngoc Nguyen, Huong Lan Thi Nguyen, Chukwudi A Nnaji, Shuhei Nomura, Ole F Norheim, Jean Jacques Noubiap, Christoph Nowak, Virginia Nunez-Samudio, Adrian Oțoiu, Felix Akpojene Ogbo, Onome Bright Oghenetega, In-Hwan Oh, Emmanuel Wandera Okunga, Morteza Oladnabi, Andrew T Olagunju, Bolajoko Olubukunola Olusanya, Jacob Olusegun Olusanya, Mojisola Morenike Oluwasanu, Ahmed Omar Bali, Muktar Omer Omer, Kanyin Liane Ong, Obinna E Onwujekwe, Doris V Ortega-Altamirano, Alberto Ortiz, Sergej M Ostojic, Nikita Otstavnov, Stanislav S Otstavnov, Simon Øverland, Mayowa O Owolabi, Jagadish Rao Padubidri, Smita Pakhale, Raffaele Palladino, Adrian Pana, Songhomitra Panda-Jonas, Helena Ullyartha Pangaribuan, Mona Pathak, George C Patton, Sagun Paudel, Hamidreza Pazoki Toroudi, Spencer A Pease, Amy E Peden, Alyssa Pennini, Emmanuel K Peprah, Jeevan Pereira, David M Pigott, Thomas Pilgrim, Tessa M Pilz, Marina Pinheiro, Michael A Piradov, Meghdad Pirsaheb, Khem Narayan Pokhrel, Maarten J Postma, Hadi Pourjafar, Farshad Pourmalek, Reza Pourmirza Kalhori, Akram Pourshams, Sergio I Prada, Dimas Ria Angga Pribadi, Elisabetta Pupillo, Zahiruddin Quazi Syed, Amir Radfar, Ata Rafiee, Alireza Rafiei, Alberto Raggi, Fakher Rahim, Muhammad Aziz Rahman, Ali Rajabpour-Sanati, Saleem Muhammad Rana, Chhabi Lal Ranabhat, Sowmya J Rao, Davide Rasella, Vahid Rashedi, Goura Kishor Rath, Priya Rathi, David Laith Rawaf, Salman Rawaf, Lal Rawal, Reza Rawassizadeh, Christian Razo, Vishnu Renjith, Andre M N Renzaho, Bhageerathy Reshmi, Nima Rezaei, Seyed Mohammad Riahi, Daniel Cury Ribeiro, Jennifer Rickard, Nicholas L S Roberts, Leonardo Roever, Michele Romoli, Luca Ronfani, Gholamreza Roshandel, Enrico Rubagotti, Godfrey M Rwegerera, Siamak Sabour, Perminder S Sachdev, Basema Saddik, Ehsan Sadeghi, Masoumeh Sadeghi, Yahya Safari, Rajesh Sagar, Amirhossein Sahebkar, Mohammad Ali Sahraian, S. Mohammad Sajadi, Mohammad Reza Salahshoor, Hosni Salem, Marwa Rashad Salem, Joshua A Salomon, Hossein Samadi Kafil, Abdallah M Samy, Juan Sanabria, Milena M Santric-Milicevic, Sivan Yegnanarayana Iyer Saraswathy, Rodrigo Sarmiento-Suárez, Benn Sartorius, Arash Sarveazad, Brijesh Sathian, Thirunavukkarasu Sathish, Davide Sattin, Miloje Savic, Susan M Sawyer, Deepak Saxena, Alyssa N Sbarra, Lauren E Schaeffer, Silvia Schiavolin, Maria Inês Schmidt, Aletta Elisabeth Schutte, David C Schwebel, Falk Schwendicke, Soraya Seedat, Feng Sha, Saeed Shahabi, Amira A Shaheen, Masood Ali Shaikh, Morteza Shamsizadeh, Mohammed Shannawaz, Kiomars Sharafi, Fablina Sharara, Hamid Sharifi, David H Shaw, Aziz Sheikh, Abbas Sheikhtaheri, B Suresh Kumar Shetty, Kenji Shibuya, Wondimeneh Shibabaw Shiferaw, Mika Shigematsu, Jae Il Shin, Rahman Shiri, Reza Shirkoohi, K M Shivakumar, Mark G Shrime, Kerem Shuval, Soraya Siabani, Radoslaw Sierpinski, Inga Dora Sigfusdottir, Rannveig Sigurvinsdottir, Diego Augusto Santos Silva, João Pedro Silva, Biagio Simonetti, Kyle E Simpson, Jasvinder A Singh, Pushpendra Singh, Dhirendra Narain Sinha, Valentin Yurievich Skryabin, Emma U R Smith, Amin Soheili, Shahin Soltani, Moslem Soofi, Reed J D. Sorensen, Joan B Soriano, Muluken Bekele Sorrie, Ireneous N Soyiri, Emma Elizabeth Spurlock, Chandrashekhar T Sreeramareddy, Jeffrey D Stanaway, Nicholas Steel, Caroline Stein, Mark A Stokes, Mu'awiyyah Babale Sufiyan, Hafiz Ansar Rasul Suleria, Iyad Sultan, Lukasz Szumowski, Rafael Tabarés-Seisdedos, Takahiro Tabuchi, Santosh Kumar Tadakamadla, Biruk Wogayehu Taddele, Degena Bahrey Tadesse, Amir Taherkhani, Animut Tagele Tamiru, Frank C Tanser, Md Ismail Tareque, Ingan Ukur Tarigan, Whitney L Teagle, Fabrizio Tediosi, Yonas Getaye Tefera, Freweini Gebrearegay G Tela, Zemenu Tadesse Tessema, Bhaskar Thakur, Mariya Vladimirovna Titova, Marcello Tonelli, Roman Topor-Madry, Fotis Topouzis, Marcos Roberto Tovani-Palone, Bach Xuan Tran, Ravensara S Travillian, Christopher E Troeger, Lorainne Tudor Car, Riaz Uddin, Irfan Ullah, Chukwuma David Umeokonkwo, Bhaskaran Unnikrishnan, Era Upadhyay, Olalekan A Uthman, Marco Vacante, Pascual R Valdez, Santosh Varughese, Tommi Juhani Vasankari, Yasser Vasseghian, Narayanaswamy Venketasubramanian, Francesco S Violante, Vasily Vlassov, Stein Emil Vollset, lAvina Vongpradith, Theo Vos, Yasir Waheed, Magdalene K Walters, Richard G Wamai, Haidong Wang, Yuan-Pang Wang, Robert G Weintraub, Jordan Weiss, Andrea Werdecker, Ronny Westerman, Lauren B Wilner, Gebremariam Woldu, Charles D A Wolfe, Ai-Min Wu, Sarah Wulf Hanson, Yang Xie, Rixing Xu, Seyed Hossein Yahyazadeh Jabbari, Kazumasa Yamagishi, Yuichiro Yano, Sanni Yaya, Vahid Yazdi-Feyzabadi, Jamal A Yearwood, Yordanos Gizachew Yeshitila, Paul Yip, Naohiro Yonemoto, Mustafa Z Younis, Zabihollah Yousefi, Taraneh Yousefinezhadi, Hasan Yusefzadeh, Siddhesh Zadey, Telma Zahirian Moghadam, Syed Saoud Zaidi, Leila Zaki, Sojib Bin Zaman, Mohammad Zamani, Maryam Zamanian, Hamed Zandian, Mikhail Sergeevich Zastrozhin, Kaleab Alemayehu Zewdie, Yunquan Zhang, Xiu-Ju George Zhao, Yingxi Zhao, Peng Zheng, Cong Zhu, Arash Ziapour, Bianca S Zlavog, Sanjay Zodpey, and Christopher J L Murray.AffiliationsInstitute for Health Metrics and Evaluation (Prof R Lozano MD, N Fullman MPH, J Mumford BA, M Knight BS, C M Barthelemy MPH, J D Adelson PhD, A Afshin MD, S B Albertson BS, C M Antony MA, A Y Aravkin PhD, K Compton BS, Prof L Dandona MD, Prof R Dandona PhD, Prof S D Dharmaratne MD, I N Dippenaar BA, T Farag PhD, Prof V L Feigin PhD, W Fu MSc, Prof E Gakidou PhD, N C Galles BS, W M Gardner AB, C Han BA, H Han MSc, Prof S I Hay FMedSci, C M S Irvine BS, D Jahagirdar PhD, N J Kassebaum MD, J M Kocarnik PhD, K J Krohn MPH, H H Kyu PhD, K M Lau BS, J R Ledesma BA, A T Leever BS, K E LeGrand MPH, Prof S S Lim PhD, Prof A D Lopez PhD, A Lu MSc, J Ma MS, I Martopullo MPH, C I Mastrogiacomo BS, Prof A H Mokdad PhD, J F Mosser MD, Prof M Naghavi MD, K L Ong PhD, S A Pease BS, A Pennini MSc, D M Pigott PhD, T M Pilz BA, C Razo PhD, N L S Roberts BS, A N Sbarra MPH, L E Schaeffer MSc, F Sharara MS, D H Shaw BA, K E Simpson BS, R J D Sorensen MPH, E E Spurlock BA, J D Stanaway PhD, R S Travillian PhD, C E Troeger MPH, Prof S Vollset DrPH, A Vongpradith BA, Prof T Vos PhD, M K Walters BS, H Wang PhD, L B Wilner MPH, S Wulf Hanson PhD, R Xu BS, J A Yearwood BS, P Zheng PhD, B S Zlavog BS, Prof C J L Murray PhD), Department of Health Metrics Sciences, School of Medicine (Prof R Lozano MD, A Afshin MD, A Y Aravkin PhD, Prof R Dandona PhD, Prof S D Dharmaratne MD, Prof E Gakidou PhD, Prof S I Hay FMedSci, N J Kassebaum MD, H H Kyu PhD, Prof S S Lim PhD, Prof A D Lopez PhD, Prof A H Mokdad PhD, Prof M Naghavi MD, D M Pigott PhD, Prof B Sartorius PhD, J D Stanaway PhD, Prof S Vollset DrPH, Prof T Vos PhD, H Wang PhD, Prof C J L Murray PhD), Department of Applied Mathematics (A Y Aravkin PhD), Division of Plastic Surgery (D Y Cho MD, C J Kneib MD), Department of Anesthesiology (A M Kamath MD), Department of Anesthesiology & Pain Medicine (N J Kassebaum MD), Department of Global Health (S Kochhar MD, R J D Sorensen MPH), Division of Plastic and Reconstructive Surgery (B B Massenburg MD, S D Morrison MD), University of Washington, Seattle, WA, USA (A Y Chang DSc); Department of Juridical and Economic Studies (C Abbafati PhD), La Sapienza University, Rome, Italy; Advanced Diagnostic and Interventional Radiology Research Center (H Abbastabar PhD), The Institute of Pharmaceutical Sciences (TIPS) (Prof M Abdollahi PhD), School of Pharmacy (Prof M Abdollahi PhD), Research Center for Immunodeficiencies (H Abolhassani PhD, Prof N Rezaei PhD), Urology Research Center (Prof S Aghamir PhD), Department of Health Policy, Management, and Economics (A Bakhtiari PhD), Multiple Sclerosis Research Center (S Eskandarieh PhD, Prof M Sahraian MD), Endocrinology and Metabolism Research Center (Prof A Esteghamati MD), School of Public Health (M Farahmand PhD), Department of Environmental Health Engineering (M Fazlzadeh PhD, H Janjani PhD), School of Medicine (N Hafezi-Nejad MD), School of Nursing and Midwifery (R Heidari-Soureshjani MSc), Department of Epidemiology and Biostatistics (Prof M Hosseini PhD, M Mansournia PhD), Pediatric Chronic Kidney Disease Research Center (Prof M Hosseini PhD), Tehran Heart Center (E Mehrabi Nasab MD), Health Equity Research Center (E Mohamadi PhD), Digestive Diseases Research Institute (Prof A Pourshams MD), Metabolomics and Genomics Research Center (F Rahim PhD), Cancer Research Institute (R Shirkoohi PhD), Cancer Biology Research Center (R Shirkoohi PhD), Tehran University of Medical Sciences, Tehran, Iran; Department of Neurology (Prof F Abd-Allah MD, A Hassan MD), National Hepatology and Tropical Medicine Research Institute (A M Khater MD), Department of Medical Parasitology (M M Khater MD), Department of Urology (Prof H Salem MD), Department of Public Health and Community Medicine (M R Salem MD), Cairo University, Cairo, Egypt; Department of Orthopaedic Surgery (A Abedi MD), University of Southern California, Los Angeles, CA, USA; Karolinska University Hospital, Huddinge, Sweden (H Abolhassani PhD); Department of Public Health (A E Abosetugn MPH), Department of Nursing (Y A Aynalem MSc, W S Shiferaw MSc), Debre Berhan University, Debre Berhan, Ethiopia; Department of Pediatric Dentistry (Prof L G Abreu PhD), Department of Maternal and Child Nursing and Public Health (Prof D C Malta PhD), Federal University of Minas Gerais, Belo Horizonte, Brazil; Department of Research (M R M Abrigo PhD), Philippine Institute for Development Studies, Quezon City, Philippines; Internal Medicine Department (A K Abu Haimed MBBS), College of Medicine (A M Almulhim MBBS), Environmental Health Department (S M A Dahlawi PhD), Pathology Department (M Madadin MD), Forensic Medicine Division (Prof R G Menezes MD), Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia; Harvard Medical School (A I Abushouk MD), T.H. Chan School of Public Health (Prof T W Bärnighausen MD), Center for Primary Care (S Basu PhD), Department of Global Health and Social Medicine (A W Eagan MSW), Cardiology Department (I Y Elgendy MD), Department of Global Health and Population (Prof O F Norheim PhD), Division of General Internal Medicine (Prof A Sheikh MD), Massachusetts Veterans Epidemiology Research and Information Center (MAVERIC) & CSP Coordinating Center (B Thakur PhD), Harvard University, Boston, MA, USA (M G Shrime MD); Department of Medicine (A I Abushouk MD), Department of Obstetrics and Gynecology (Prof A F Nabhan PhD), Department of Entomology (A M Samy PhD), Ain Shams University, Cairo, Egypt; Department of Anesthesiology (M Bakhshaei MD), Autism Spectrum Disorders Research Center (E Jenabi PhD), Department of Biostatistics (N Mohammad Gholi Mezerji MSc), Department of Cardiology (B Naghshtabrizi MD), Research Center for Molecular Medicine (A Taherkhani PhD), Hamedan University of Medical Sciences, Hamadan, Iran (M Adabi PhD); College of Medicine (O M Adebayo MD), Department of Community Medicine (O S Ilesanmi PhD), Department of Medicine (Prof M O Owolabi DrM), University College Hospital, Ibadan, Ibadan, Nigeria; School of Medicine (V Adekanmbi PhD), Cardiff University, Cardiff, UK; Centre of Excellence for Epidemiological Modelling and Analysis (O O Adetokunboh PhD), Department of Global Health (O O Adetokunboh PhD, C J Iwu PhD), Department of Psychiatry (Prof S Seedat PhD), Stellenbosch University, Cape Town, South Africa; School of Health (D Adham PhD), Department of Environmental Health Engineering (M Fazlzadeh PhD), Social Determinants of Health Research Center (T Zahirian Moghadam PhD, H Zandian PhD), Department of Community Medicine (H Zandian PhD), Ardabil University of Medical Science, Ardabil, Iran; Social Behavioral Research Branch (S M Advani PhD), National Eye Institute (W L Teagle BA), National Institute of Health, Bethesda, MD, USA; Department of Oncology (S M Advani PhD), Georgetown University, Washington DC, USA; Department of Family Medicine (Prof G Agarwal PhD), Department of Medicine (O P Kurmi PhD), Department of Psychiatry and Behavioural Neurosciences (A T Olagunju MD), Population Health Research Institute (T Sathish PhD), McMaster University, Hamilton, ON, Canada; Department of Cardiovascular Medicine (P Agasthi MD), Mayo Clinic, Scottsdale, AZ, USA; Institute of Genomics and Integrative Biology (Prof A Agrawal PhD), Council of Scientific & Industrial Research, Delhi, India; Internal Medicine (Prof A Agrawal PhD), Baylor College of Medicine, Houston, TX, USA; Department of Epidemiology and Health Statistics (T Ahmad MS), Southeast University, Nanjing, China; Institute for Advanced Medical Research and Training (R O Akinyemi PhD), Department of Health Promotion and Education (S E Ibitoye MPH, Y O John-Akinola PhD, M M Oluwasanu PhD), Department of Community Medicine (O S Ilesanmi PhD), Department of Obstetrics and Gynecology (O B Oghenetega MSc), Department of Medicine (Prof M O Owolabi DrM), University of Ibadan, Ibadan, Nigeria; Institute of Neuroscience (R O Akinyemi PhD), Newcastle University, Newcastle upon Tyne, UK; Mayo Evidence-based Practice Center (F Alahdab MSc), Mayo Clinic Foundation for Medical Education and Research, Rochester, MN, USA; John T. Milliken Department of Internal Medicine (Z Al-Aly MD), Washington University in St. Louis, St. Louis, MO, USA; Clinical Epidemiology Center (Z Al-Aly MD), Department of Veterans Affairs, St Louis, MO, USA; Murdoch Business School (K Alam PhD), Murdoch University, Perth, WA, Australia; Department of Epidemiology and Biostatistics (Y Alemu MPH), Department of Midwifery (S A Bante MSc), Department of Medical Laboratory Sciences (A Melese MSc), Bahir Dar University, Bahir Dar, Ethiopia; Institute of Health Research (R K Alhassan PhD), Department of Health Policy Planning and Management (M A Ayanore PhD), Department of Family and Community Health (N Kugbey PhD), University of Health and Allied Sciences, Ho, Ghana; Department of Biotechnology (M Ali PhD), Quaid-i-Azam University, Islamabad, Pakistan; Department of Information Systems, College of Economics and Political Science (S Ali PhD), Sultan Qaboos University, Muscat, Oman; Health Management and Economics Research Center (V Alipour PhD, J Arabloo PhD, S Azari PhD, A Ghashghaee BSc), Health Economics Department (V Alipour PhD), Preventive Medicine and Public Health Research Center (M Asadi-Aliabadi MSc, E Babaee PhD, S Goharinezhad PhD, M Moradi-Lakeh MD), Faculty of Allied Medicine (F Dorostkar PhD), Student Research Committee (A Ghashghaee BSc), Nutrition Health Research Center (F Mehri PhD), Department of Physiology (H Pazoki Toroudi PhD), Physiology Research Center (H Pazoki Toroudi PhD), Tehran Institute of Psychiatry (V Rashedi PhD), Colorectal Research Center (A Sarveazad PhD), Health Information Management (A Sheikhtaheri PhD), Iran University of Medical Sciences, Tehran, Iran; Department of Health Policy and Management (Prof S M Aljunid PhD), Kuwait University, Safat, Kuwait; International Centre for Casemix and Clinical Coding (Prof S M Aljunid PhD), National University of Malaysia, Bandar Tun Razak, Malaysia; Bordeaux School of Public Health (Prof F Alla PhD), University of Bordeaux, Bordeaux, France; College of Medicine (M A H Almadi FRCPC), Pediatric Intensive Care Unit (K A Altirkawi MD), Internal Medicine Department (Y Mohammad MD), King Saud University, Riyadh, Saudi Arabia; Division of Gastroenterology & Hepatology (M A H Almadi FRCPC), McGill University, Montreal, QC, Canada; Department of Environmental Health Engineering (Prof A Almasi PhD), Department of Radiology and Nuclear Medicine (F Amiri MSc), Infectious Disease Research Center (Prof K Ghadiri MD), Pediatric Department (Prof K Ghadiri MD), Research Center for Environmental Determinants of Health (Prof B Karami Matin PhD, M Moradi PhD, Prof M Pirsaheb PhD, Prof E Sadeghi PhD, Y Safari PhD, K Sharafi PhD, S Soltani PhD, Y Vasseghian PhD), Department of Public Health (N Kianipour MA), Clinical Research Development Center (S Maleki MSc, M Naderi PhD), Substance Abuse Prevention Research Center (B Mansouri PhD), Department of Rehabilitation and Sports Medicine (M Mirzaei MSc), Social Development and Health Promotion Research Center (M Mirzaei-Alavijeh PhD, M Soofi PhD), Department of Emergency Medicine (R Pourmirza Kalhori PhD), Department of Anatomical Sciences (M R Salahshoor PhD), Department of Health Education and Health Promotion (S Siabani PhD, A Ziapour PhD), Kermanshah University of Medical Sciences, Kermanshah, Iran (H Janjani PhD); Department of Epidemiology (A Almasi-Hashiani PhD, R Moradzadeh PhD, M Zamanian PhD), Health Services Management Department (S Amini PhD), Department of Pediatrics (J Nazari MD), Arak University of Medical Sciences, Arak, Iran; Physiotherapy Department (Prof N A Almasri PhD), The University of Jordan, Amman, Jordan; Medical Research Center (H M Al-Mekhlafi PhD), Epidemiology Department (M Khan MD), Jazan University, Jazan, Saudi Arabia (Prof N Bedi MD); Department of Parasitology (H M Al-Mekhlafi PhD), Sana'a University, Sana'a, Yemen; Research Program of Epidemiology and Public Health (J Alonso MD), Pompeu Fabra University, Barcelona, Spain; Department of Experimental and Health Sciences (J Alonso MD), Biomedical Research Networking Center in Epidemiology and Public Health (CiberESP), Madrid, Spain; Department of Community Medicine (R M Al-Raddadi PhD), King Abdulaziz University, Jeddah, Saudi Arabia; Research Group in Health Economics (Prof N Alvis-Guzman PhD), University of Cartagena, Cartagena, Colombia; Research Group in Hospital Management and Health Policies (Prof N Alvis-Guzman PhD), Universidad de la Costa, Barranquilla, Colombia; Department of Economic Sciences (N J Alvis-Zakzuk MSc), University of the Coast, Barranquilla, Colombia; Colombian National Health Observatory (N J Alvis-Zakzuk MSc, C A Castañeda-Orjuela MD), Department of Public Health Research (J N Malagón-Rojas MSc), National Institute of Health, Bogota, Colombia; Health Management and Economics Reasearch Center (M Amini-Rarani PhD), Department of Immunology (M Jafarinia MSc), Cardiac Rehabilitation Research Center (Prof M Sadeghi MD), Isfahan University of Medical Sciences, Isfahan, Iran; Department of Epidemiology and Biostatistics (A L Amit BS), Department of Health Policy and Administration (C T Antonio MD, E A Faraon MD), University of the Philippines Manila, Manila, Philippines; School of Public Health (A L Amit BS), Department of Radiology and Radiological Sciences (N Hafezi-Nejad MD), Johns Hopkins University, Baltimore, MD, USA; Maternal and Child Wellbeing (D A Amugsi PhD), African Population and Health Research Center, Nairobi, Kenya; Department of Pharmacy (R Ancuceanu PhD), Department of Cardiology (C Andrei PhD), Department of Internal Medicine (M Hostiuc PhD), Department of Legal Medicine and Bioethics (S Hostiuc PhD), Department of General Surgery (I Negoi PhD), Department of Anatomy and Embryology (R I Negoi PhD), Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; Centre for Sensorimotor Performance (D Anderlini MD), School of Health and Rehabilitation Sciences (R Uddin PhD), The University of Queensland, Brisbane, Australia; Neurology Department (D Anderlini MD), Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia; Department of Medicine (S Androudi PhD), University of Thessaly, Volos, Greece; Research Center for Evidence Based Medicine (F Ansari PhD), Department of Health Policy and Management (L Doshmangir PhD), Department of Medical Surgical Nursing (M Ghafourifard PhD), School of Nursing and Midwifery (H Hassankhani PhD), Department of Immunology (F Jadidi-Niaragh PhD), Health Services Management Research Center (L R Kalankesh PhD), Biotechnology Research Center (M Moghadaszadeh PhD), Molecular Medicine Research Center (M Moghadaszadeh PhD), Drug Applied Research Center (H Samadi Kafil PhD), Tabriz University of Medical Sciences, Tabriz, Iran; Razi Vaccine and Serum Research Institute (F Ansari PhD), Agricultural Research, Education, and Extension Organization (AREEO), Tehran, Iran; Department of Epidemiology and Biostatistics (Prof A Ansari-Moghaddam PhD), Health Promotion Research Center (M Khammarnia PhD), Zahedan University of Medical Sciences, Zahedan, Iran; Department of Applied Social Sciences (C T Antonio MD), School of Nursing (P H Lee PhD), Hong Kong Polytechnic University, Hong Kong, China; Agribusiness Study Program (E Antriyandarti DrAgrSc), Sebelas Maret University, Surakarta, Indonesia; Department of Parasitology (D Anvari PhD), Toxoplasmosis Research Center (Prof A Daryani PhD), Faculty of Nursing and Midwifery (A Goudarzian MSc), Department of Immunology (Prof A Rafiei PhD), Molecular and Cell Biology Research Center (Prof A Rafiei PhD), Department of Environmental Health (Prof Z Yousefi PhD), Mazandaran University of Medical Sciences, Sari, Iran; Department of Parasitology (D Anvari PhD), Iranshahr University of Medical Sciences, Iranshahr, Iran; Department of Pathology (R Anwer PhD), Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia; Social Determinants of Health Research Center (M Arab-Zozani PhD), Faculty of Medicine (A Rajabpour-Sanati MD), Cardiovascular Diseases Research Center (S Riahi PhD), Birjand University of Medical Sciences, Birjand, Iran; Department of Public Health (O Aremu PhD), Birmingham City University, Birmingham, UK; Department of Neurobiology, Care Sciences and Society (Prof J Ärnlöv PhD, C Nowak PhD), Department of Medical Epidemiology and Biostatistics (Prof J J Carrero PhD), Department of Physiology and Pharmacology (C R Cederroth PhD), Department of Medicine (D K Mohammad PhD), Karolinska Institutet, Stockholm, Sweden; School of Health and Social Studies (Prof J Ärnlöv PhD), Dalarna University, Falun, Sweden; Department of Plastic Surgery (M Asaad MD), University of Texas, Houston, TX, USA; Epilepsy Research Center (Prof A A Asadi-Pooya MD), Department of Healthcare Management and Education (M Bahrami PhD), Health Human Resources Research Center (M Bayati PhD), Department of Epidemiology (M Dianatinasab MSc), Health Policy Research Center (S Shahabi PhD), Shiraz University of Medical Sciences, Shiraz, Iran; Neurology Department (Prof A A Asadi-Pooya MD), Thomas Jefferson University, Philadelphia, PA, USA; Department of Immunology (S Athari MPH), Zanjan University of Medical Sciences, Zanjan, Iran; Faculty of Nursing (M M W Atout PhD), Philadelphia University, Amman, Jordan; School of Business (Prof M Ausloos PhD), University of Leicester, Leicester, UK; Department of Statistics and Econometrics (Prof M Ausloos PhD, Prof C Herteliu PhD, A Oțoiu PhD, A Pana MD), Bucharest University of Economic Studies, Bucharest, Romania; Center for Health Systems Research (L Avila-Burgos ScD), Center for Nutrition and Health Research (E Denova-Gutiérrez DSc), Health Systems Research Center (D V Ortega-Altamirano DrPH), National Institute of Public Health, Cuernavaca, Mexico; The Judith Lumley Centre (B Ayala Quintanilla PhD), School of Nursing and Midwifery (Prof D Edvardsson PhD, M Rahman PhD), Department of Public Health (M Islam PhD), La Trobe University, Melbourne, VIC, Australia; School of Public Health (G Ayano MSc, D Hendrie PhD), School of Physiotherapy and Exercise Science (Prof A M Briggs PhD), Curtin University, Perth, WA, Australia; Department of Clinical Midwifery (G L Aynalem MSc), Department of Midwifery (A T Tamiru MSc), Department of Clinical Pharmacy (Y G Tefera MSc), Department of Epidemiology and Biostatistics (Z T Tessema MSc), University of Gondar, Gondar, Ethiopia; Department of Pharmacology and Toxicology (M A Ayza MSc), Department of Nursing (G G Gebremeskel MSc), Department of Pharmacy (L G Gebremeskel MSc), Department of Epidemiology (H A Gesesew PhD), School of Public Health (F G G Tela BHlthSci), School of Pharmacy (K A Zewdie MSc), Mekelle University, Mekelle, Ethiopia; Global Adolescent Health Group (P S Azzopardi PhD), Burnet Institute, Melbourne, VIC, Australia; Wardliparingga Aboriginal Research Unit (P S Azzopardi PhD), South Australian Health and Medical Research Institute, Adelaide, SA, Australia; Department of Community Medicine (D B B MD, V Kulkarni MD, N Kumar MD), Department of Forensic Medicine and Toxicology (S M Bakkannavar MD, Prof V C Nayak MD, Prof B K Shetty MD), Department of Health Information Management (R Bhageerathy PhD), Department of Internal Medicine (A Boloor MD), Kasturba Medical College (R Holla MD, Prof B Unnikrishnan MD), Centre for Bio Cultural Studies (CBiCS) (P Hoogar PhD), Department of Forensic Medicine (J Padubidri MD), Kasturba Medical College, Mangalore (P Rathi MD), Manipal Academy of Higher Education, Mangalore, India (R Bhageerathy PhD, Prof V Jha MD); Department of Forensic Science (A D Badiye MSc, N Kapoor MSc), Government Institute of Forensic Science, Nagpur, India; Unit of Biochemistry (A A Baig PhD), Sultan Zainal Abidin University, Kuala Terengganu, Malaysia; Department of Demography (A Balachandran MSc), University Medical Center Groningen (Prof M J Postma PhD), School of Economics and Business (Prof M J Postma PhD), University of Groningen, Groningen, Netherlands; Population Research Centre (A Balachandran MSc), Institute for Social and Economic Change, Bengaluru, India; Department of Hypertension (Prof M Banach PhD), Medical University of Lodz, Lodz, Poland; Polish Mothers' Memorial Hospital Research Institute, Lodz, Poland (Prof M Banach PhD); School of Health Sciences (Prof S K Banerjee PhD), Walden University, Minneapolis, MN, USA; Department of Non-communicable Diseases (P C Banik MPhil), Bangladesh University of Health Sciences, Dhaka, Bangladesh; Department of Nursing (A B Bante MSc, Y G Yeshitila MSc), Department of Public Health (M Glagn MPH, M B Sorrie MPH), Department of Midwifery (T Gultie MSc), Arba Minch University, Arba Minch, Ethiopia; School of Psychology (Prof S L Barker-Collo PhD), University of Auckland, Auckland, New Zealand; Heidelberg Institute of Global Health (HIGH) (Prof T W Bärnighausen MD, J De Neve MD, S Kohler MD, B Moazen MSc, S Mohammed PhD), Department of Ophthalmology (Prof J B Jonas MD, S Panda-Jonas MD), Heidelberg University, Heidelberg, Germany; Department of Industrial Engineering (Prof L H Barrero DSc), Pontifical Javeriana University, Bogota, Colombia; Barcelona Institute for Global Health (Prof Q Bassat MD), Research Unit (J M Haro MD), University of Barcelona, Barcelona, Spain; Catalan Institution for Research and Advanced Studies (ICREA), Barcelona, Spain (Prof Q Bassat MD, A Koyanagi MD); School of Public Health (S Basu PhD), Imperial College Business School (D Kusuma DSc), Department of Primary Care and Public Health (Prof A Majeed MD, R Palladino MD, Prof S Rawaf MD), WHO Collaborating Centre for Public Health Education and Training (D L Rawaf MD), Imperial College London, London, UK; Department of Psychiatry (Prof B T Baune PhD), University of Münster, Münster, Germany; Department of Psychiatry (Prof B T Baune PhD), Melbourne Medical School, Melbourne, VIC, Australia; Department of Public Health (B A Baye MPH, J Darega Gela MPH), Ambo University, Ambo, Ethiopia; Department of Community Medicine (Prof N Bedi MD), Gandhi Medical College Bhopal, Bhopal, India; Department of Neuroscience (E Beghi MD, E Pupillo PharmD), Department of Environmental Health Sciences (S Gallus DSc), Laboratory of Neurological Disorders (G Giussani PhD), Mario Negri Institute for Pharmacological Research, Milan, Italy (B Bikbov MD); Social Determinants of Health Research Center (M Behzadifar PhD), Lorestan University of Medical Sciences, Khorramabad, Iran; Department of Public Health (T T Bekuma MPH), Wollega University, Nekemte, Ethiopia; School of the Environment (Prof M L Bell PhD), Yale University, New Haven, CT, USA; Department of Internal Medicine (I M Bensenor PhD), Department of Psychiatry (Prof J Castaldelli-Maia PhD, Y Wang PhD), Division of Ophthalmology (J M Furtado MD), Department of Medicine (Prof P A Lotufo DrPH), Department of Pathology and Legal Medicine (M R Tovani-Palone PhD), University of São Paulo, São Paulo, Brazil; Department of Medicine (A E Berman MD), Medical College of Georgia at Augusta University, Augusta, GA, USA; Faculty of Dentistry, Oral & Craniofacial Sciences (E Bernabe PhD), Institute for Population Health (Prof K Shibuya MD), School of Population Health and Environmental Sciences (Prof C D A Wolfe MD), King's College London, London, UK; Hubert Department of Global Health (R S Bernstein MD), Emory University, Atlanta, GA, USA; Department of Internal Medicine (A S Bhagavathula PharmD), United Arab Emirates University, Al Ain, United Arab Emirates; Department of Social and Clinical Pharmacy (A S Bhagavathula PharmD), Charles University, Prague, Czech Republic; School of Public Health (D Bhandari MSc), Adelaide Medical School (L G Ciobanu PhD, T K Gill PhD), Centre for Heart Rhythm Disorders (J Noubiap MD), University of Adelaide, Adelaide, SA, Australia; Public Health Research Laboratory (D Bhandari MSc), Tribhuvan University, Kathmandu, Nepal; Department of Community Medicine and Family Medicine (P Bhardwaj MD), Department of Pharmacology (J Charan MD), Department of Forensic Medicine and Toxicology (T Kanchan MD), Department of Radiation Oncology (Prof G K Rath MD), Department of Psychiatry (Prof R Sagar MD), All India Institute of Medical Sciences, New Delhi, India; Division of General Internal Medicine (A G Bhat MD), University of Massachusetts Medical School, Springfield, MA, USA; Department of Statistical and Computational Genomics (K Bhattacharyya MSc), National Institute of Biomedical Genomics, Kalyani, India; Department of Statistics (K Bhattacharyya MSc), University of Calcutta, Kolkata, India; Department of Global Health (S Bhattarai MD), Global Institute for Interdisciplinary Studies, Kathmandu, Nepal; Centre for Global Child Health (Prof Z A Bhutta PhD), Department of Medicine (V Chattu MD), University of Toronto, Toronto, ON, Canada; Centre of Excellence in Women & Child Health (Prof Z A Bhutta PhD), Aga Khan University, Karachi, Pakistan; Social Determinants of Health Research Center (A Bijani PhD, M A Jahani PhD), Department of Clinical Biochemistry (A Mosapour PhD), Student Research Committee (M Zamani MD), Babol University of Medical Sciences, Babol, Iran; Health Economics and Outcomes Research (V Bilano PhD), Creativ-Ceutical, London, UK; Department of General Surgery and Medical-Surgical Specialties (Prof A Biondi PhD, M Vacante PhD), University of Catania, Catania, Italy; Ethiopian Public Health Institute, Addis Ababa, Ethiopia (B M Birihane MSc); Department of Nursing (B M Birihane MSc), Debre Tabor University, Debretabor, Ethiopia; European & Developing Countries Clinical Trials Partnership, Cape Town, South Africa (Prof M J Bockarie MSc); Department of Medicine (Prof M J Bockarie MSc, G A Mensah MD), School of Public Health and Family Medicine (C A Nnaji MPH), University of Cape Town, Cape Town, South Africa; Department of Veterinary Medicine (S Bohlouli PhD), Tehran Medical Sciences Branch (S Esmaeilnejad PhD), Young Researchers and Elite Club (A Gholamian MSc), Department of Biology (A Gholamian MSc), Islamic Azad University, Kermanshah, Iran; School of Pharmacy (H A Bojia BPharm), Department of Medical Laboratory Sciences (A M Gebrehiwot PhD), Haramaya University, Harar, Ethiopia; Department of Biomedical Sciences (S R Bolla PhD), Nazarbayev University, Nur-Sultan City, Kazakhstan; Department of Infectious Disease Epidemiology (O J Brady PhD), MSc Epidemiology Programme (A Hafiz PhD), European Observatory on Health Systems and Policies (M Karanikolos PhD), Department of Health Services Research and Policy (M Karanikolos PhD, Prof M McKee DSc), Faculty of Infectious and Tropical Diseases (Prof B Sartorius PhD), London School of Hygiene & Tropical Medicine, London, UK; Division of Hematology and Oncology (D Braithwaite PhD), Georgetown University, Washington, DC, USA; Department of Epidemiology and Evidence Based Medicine (Prof N I Briko DSc), N. A. Semashko Department of Public Health and Healthcare (Prof M Jakovljevic PhD), Department of Epidemiology and Evidence-Based Medicine (V A Korshunov PhD, P D Lopukhov PhD), I.M. Sechenov First Moscow State Medical University, Moscow, Russia; Department of Community Medicine (Prof S Burugina Nagaraja MD), Employee State Insurance Post Graduate Institute of Medical Sciences and Research, Bangalore, India; Department of Health Care Management (Prof R Busse PhD), Technical University of Berlin, Berlin, Germany; School of Public Health and Health Systems (Z A Butt PhD), University of Waterloo, Waterloo, ON, Canada; Al Shifa School of Public Health (Z A Butt PhD), Al Shifa Trust Eye Hospital, Rawalpindi, Pakistan; Institute of Microengineering (F Caetano dos Santos PhD), Federal Polytechnic School of Lausanne, Lausanne, Switzerland; School of Public Health and Administration (L Cahuana-Hurtado PhD), Peruvian University Cayetano Heredia, Lima, Peru; Internal Medicine Department (Prof L A Cámera MD), Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Board of Directors (Prof L A Cámera MD), Argentine Society of Medicine, Buenos Aires, Argentina (Prof P R Valdez MEd); Department of Health Care (Prof R Cárdenas DSc), Metropolitan Autonomous University, Mexico City, Mexico; Institute for Cancer Research, Prevention and Clinical Network, Florence, Italy (G Carreras PhD); Research Unit on Applied Molecular Biosciences (UCIBIO) (Prof F Carvalho PhD, V M Costa PhD, J P Silva PhD), Laboratory of Toxicology (Prof D Dias da Silva PhD), Associated Laboratory for Green Chemistry (LAQV) (Prof E Fernandes PhD), University Hospital Center of Porto (J Morgado-da-Costa MSc), Department of Chemistry (M Pinheiro PhD), University of Porto, Porto, Portugal; Epidemiology and Public Health Evaluation Group (C A Castañeda-Orjuela MD), National University of Colombia, Bogota, Colombia; Department of Medicine (G Castelpietra PhD), University of Udine, Udine, Italy; Department of Mental Health (G Castelpietra PhD), Healthcare Agency “Friuli Occidentale”, Pordenone, Italy; Gorgas Memorial Institute for Health Studies, Panama City, Panama (F Castro MD); National School of Public Health (F Catalá-López PhD), Institute of Health Carlos III, Madrid, Spain; Clinical Epidemiology Program (F Catalá-López PhD), Department of Medicine (S Pakhale MD), Ottawa Hospital Research Institute, Ottawa, ON, Canada; National Institute of Health Research Nottingham Biomedical Research Centre (C R Cederroth PhD), University of Nottingham, Nottingham, UK; Mary MacKillop Institute for Health Research (Prof E Cerin PhD), Australian Catholic University, Melbourne, VIC, Australia; School of Public Health (Prof E Cerin PhD), Department of Urban Planning and Design (H Ho PhD), Centre for Suicide Research and Prevention (Prof P Yip PhD), Department of Social Work and Social Administration (Prof P Yip PhD), University of Hong Kong, Hong Kong, China; Institute of Applied Health Research (J S Chandan MFPH), Institute of Occupational and Environmental Medicine (O P Kurmi PhD), University of Birmingham, Birmingham, UK; Research Department (S Chaturvedi PhD), Dr D Y Patil University, Pune, India; Department of Epidemiology and Preventive Medicine (K L Chin PhD), School of Public Health and Preventive Medicine (S Li PhD), The School of Clinical Sciences at Monash Health (S Zaman MPH), Monash University, Melbourne, VIC, Australia; Melbourne Medical School (K L Chin PhD), Melbourne School of Population and Global Health (Prof A D Lopez PhD), School of Health Sciences (A Meretoja MD), Department of Pediatrics (Prof G C Patton MD, Prof S M Sawyer MD), Department of Agriculture and Food Systems (H Suleria PhD), University of Melbourne, Melbourne, VIC, Australia; Biomedical Informatics (J J Choi PhD), Seoul National University Hospital, Seoul, South Korea; Bispebjerg Hospital (Prof H Christensen DMSci), University of Copenhagen, Copenhagen, Denmark; Faculty of Biology (D Chu PhD), Hanoi National University of Education, Hanoi, Vietnam; Department of Otolaryngology (M T Chung MD), Wayne State University, Detroit, MI, USA; School of Pharmacy and Medical Sciences (L G Ciobanu PhD), University of South Australia, Adelaide, SA, Australia; Department of Public Health (Prof M Cirillo MD, Prof I Iavicoli PhD, R Palladino MD), University of Naples Federico II, Naples, Italy; School of Medicine and Surgery (P A Cortesi PhD), Research Center on Public Health (P Ferrara MD), University of Milan Bicocca, Monza, Italy; Postgraduate Program in Epidemiology (E Cousin PhD, Prof B B Duncan PhD, Prof B N G Goulart DSc, Prof M I Schmidt PhD, C Stein PhD), Federal University of Rio Grande do Sul, Porto Alegre, Brazil; Clinical Dermatology, IRCCS Istituto Ortopedico Galeazzi (G Damiani MD), Department of Clinical Sciences and Community Health (Prof C La Vecchia MD), University of Milan, Milan, Italy; Department of Dermatology (G Damiani MD), Department of Nutrition and Preventive Medicine (Prof J Sanabria MD), Case Western Reserve University, Cleveland, OH, USA; Health Policy Research (M R Mathur PhD), Indian Institute of Public Health (Prof S Zodpey PhD), Public Health Foundation of India, Gurugram, India (Prof L Dandona MD, Prof R Dandona PhD, G Kumar PhD, D K Lal MD); India Cancer Research Consortium (Prof R Mehrotra DPhil), Indian Council of Medical Research, New Delhi, India (Prof L Dandona MD); Department of Information Technology (A M Darwesh PhD), Department of Computer Science (M Hosseinzadeh PhD), University of Human Development, Sulaymaniyah, Iraq; Central University Tami Nadu, Thiruvarur, India (Prof A P Dash DSc); Department of Global Health and Infection (Prof G Davey MD), Wellcome Trust Brighton and Sussex Centre for Global Health Research (K Deribe PhD), Brighton and Sussex Medical School, Brighton, UK; School of Public Health (Prof G Davey MD, K Deribe PhD), Addis Ababa University, Addis Ababa, Ethiopia; Department of Population and Development (C A Dávila-Cervantes PhD), Latin American Faculty of Social Sciences Mexico, Mexico City, Mexico; Health Research Institute (K Davletov PhD), Al Farabi Kazakh National University, Almaty, Kazakhstan; St Paul's Eye Unit (N Dervenis MD), Royal Liverpool University Hospital, Liverpool, UK; Department of Ophthalmology (N Dervenis MD), 1st Department of Ophthalmology (Prof F Topouzis PhD), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiology (R Desai MBBS), Atlanta Veterans Affairs Medical Center, Decatur, GA, USA; Department of Community Medicine (Prof S D Dharmaratne MD), University of Peradeniya, Peradeniya, Sri Lanka; Department of Microbiology (G P Dhungana MSc), Far Western University, Mahendranagar, Nepal; Department of Epidemiology and Biostatistics (M Dianatinasab MSc), Shahroud University of Medical Sciences, Shahroud, Iran; Center of Complexity Sciences (Prof D Diaz PhD), National Autonomous University of Mexico, Mexico City, Mexico; Faculty of Veterinary Medicine and Zootechnics (Prof D Diaz PhD), Autonomous University of Sinaloa, Culiacan Rosales, Mexico; Center of Excellence in Public Health Nutrition (H T Do MD), Nguyen Tat Thanh University, Ho Chi Minh City, Vietnam; School of Medicine (Prof A R Duraes PhD), Institute of Collective Health (Prof D Rasella PhD), Federal University of Bahia, Salvador, Brazil; Department of Internal Medicine (Prof A R Duraes PhD), Escola Bahiana de Medicina e Saúde Pública, Salvador, Brazil; Department of Social Services (A W Eagan MSW), Tufts Medical Center, Boston, MA, USA; Department of Nursing (Prof D Edvardsson PhD), Umeå University, Umea, Sweden; Biomedical Informatics and Medical Statistics Department (I El Sayed PhD), Pediatric Dentistry and Dental Public Health Department (Prof M El Tantawi PhD), Alexandria University, Alexandria, Egypt; Division of Cardiology (I Y Elgendy MD), Massachusetts General Hospital, Boston, MA, USA; Eijkman-Oxford Clinical Research Unit (I R Elyazar PhD), Eijkman Institute for Molecular Biology, Jakarta, Indonesia; Department of Medicinal Chemistry (K Eskandari PhD), Pharmaceutics Research Center (K Eskandari PhD), HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance (Prof H Sharifi PhD), Health Services Management Research Center (V Yazdi-Feyzabadi PhD), Department of Health Management, Policy, and Economics (V Yazdi-Feyzabadi PhD), Kerman University of Medical Sciences, Kerman, Iran; Department of Physiology (S Esmaeilnejad PhD), Department of Clinical Biochemistry (A Mosapour PhD), Department of Parasitology and Entomology (L Zaki PhD), Tarbiat Modares University, Tehran, Iran; Independent Consultant, Awka, Nigeria (O Ezekannagha PhD); International Institute for Tropical Agriculture, Ibadan, Nigeria (O Ezekannagha PhD); Dissemination Division (C S e Farinha MSc), National Institute of Statistics, Lisbon, Portugal; Activity Planning and Control Unit (C S e Farinha MSc), Directorate-General of Health (DGS), Lisbon, Portugal; Department of Medical and Surgical Sciences (A Farioli PhD, Prof F S Violante MD), University of Bologna, Bologna, Italy; Department of Biology and Biotechnology “Lazzaro Spallanzani” (P S Faris PhD), University of Pavia, Pavia, Italy; Department of Biology (P S Faris PhD), Department of Forestry (D K Mohammad PhD), Salahaddin University-Erbil, Erbil, Iraq; Department of Psychology (Prof A Faro PhD), Federal University of Sergipe, São Cristóvão, Brazil; National Institute for Stroke and Applied Neurosciences (Prof V L Feigin PhD), Auckland University of Technology, Auckland, New Zealand; Third Department of Neurology (E V Gnedovskaya PhD), Research Center of Neurology, Moscow, Russia (Prof V L Feigin PhD, Prof M A Piradov DSc); Department of Health Education and Behavioral Sciences (G T Feyissa PhD), Jimma University, Jimma, Ethiopia; Psychiatry Department (I Filip MD), Kaiser Permanente, Fontana, CA, USA; School of Health Sciences (I Filip MD), A.T. Still University, Mesa, AZ, USA; Institute of Gerontological Health Services and Nursing Research (F Fischer PhD), Ravensburg-Weingarten University of Applied Sciences, Weingarten, Germany; James Cancer Hospital (J L Fisher PhD), Ohio State University, Columbus, OH, USA; Sergio Arouca National School of Public Health, Rio de Janeiro, Brazil (L S Flor MPH); Federal University of Espírito Santo, Vitória, Brazil (L S Flor MPH); Institute of Gerontology (N A Foigt PhD), National Academy of Medical Sciences of Ukraine, Kyiv, Ukraine; Department of Child Dental Health (Prof M O Folayan FWACS), Obafemi Awolowo University, Ile-Ife, Nigeria; Department of Cell Biology and Biotechnology (A A Fomenkov PhD), Timiryazev Institute of Plant Physiology, Moscow, Russia; Abadan Faculty of Medical Sciences (M Foroutan PhD), Abadan School of Medical Sciences, Abadan, Iran; Department of Family Medicine and Primary Care (J M Francis PhD), University of the Witwatersrand, Johannesburg, South Africa; Department of Dermatology (T Fukumoto PhD), Kobe University, Kobe, Japan; Department of Cardiovascular Medicine (M M Gad MD), Cleveland Clinic, Cleveland, OH, USA; Gillings School of Global Public Health (M M Gad MD), University of North Carolina Chapel Hill, Chapel Hill, NC, USA; Department of Community Medicine (Prof A M Gaidhane MD, Prof Z Quazi Syed PhD, Prof D Saxena PhD), Global Evidence Synthesis Initiative (Prof M Khatib PhD), Datta Meghe Institute of Medical Sciences, Wardha, India; Department of Public Health (B S Geberemariyam MPH), Madda Walabu University, Bale Robe, Ethiopia; Department of Nursing (G G Gebremeskel MSc, T G Haile MSc, D B Tadesse MSc), School of Pharmacy (L G Gebremeskel MSc, G Woldu MSc), Aksum University, Aksum, Ethiopia; College of Medicine and Public Health (H A Gesesew PhD), Flinders University, Adelaide, SA, Australia; Research Group for Genomic Epidemiology (N Ghith PhD), Technical University of Denmark, Copenhagen, Denmark; Faculty of Allied Health Sciences (Prof S Gilani PhD), University Institute of Public Health (S Hameed MPH, A Hanif PhD, Prof S M Rana PhD), The University of Lahore, Lahore, Pakistan; Afro-Asian Institute, Lahore, Pakistan (Prof S Gilani PhD); Medical School (Prof P S Gill DM), Division of Health Sciences (O A Uthman PhD), University of Warwick, Coventry, UK; Discipline of Public Health Medicine (T G Ginindza PhD), University of KwaZulu-Natal, Durban, South Africa (Prof F C Tanser PhD); Department of Pediatrics (M Gitimoghaddam MD), School of Population and Public Health (J A Kopec PhD, F Pourmalek PhD), University of British Columbia, Vancouver, BC, Canada; School of Public Health and Community Medicine (M A Godinho MBBS, A E Peden PhD), The George Institute for Global Health (Prof V Jha MD), School of Psychiatry (Prof P B Mitchell MD, Prof P S Sachdev MD), University of New South Wales, Sydney, NSW, Australia; Hudson College of Public Health (S V Gopalani MPH), University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA; Department of Health and Social Affairs (S V Gopalani MPH), Government of the Federated States of Micronesia, Palikir, Federated States of Micronesia; Department of Family and Community Medicine (M I M Gubari PhD), University Of Sulaimani, Sulaimani, Iraq; Institute of Tropical Pathology and Public Health (IPTSP) (R A Guimarães MSc), Federal University of Goias, Goiânia, Brazil; College of Medicine and Health Science (R A Guled PhD), Department of Public Health (A Hashi PhD, M O Omer MSc), Jigjiga University, Jijiga, Ethiopia; Department of Epidemiology (Prof Y Guo PhD), Binzhou Medical University, Yantai City, China; Medical Resources (Prof R Gupta MD), March of Dimes, Arlington, VA, USA; Health Policy, Management and Leadership (Prof R Gupta MD), West Virginia University School of Public Health, Morgantown, WV, USA; Department of Preventive Cardiology (Prof R Gupta MD), Eternal Heart Care Centre & Research Institute, Jaipur, India; Department of Medicine (Prof R Gupta MD), Mahatma Gandhi University Medical Sciences, Jaipur, India; College of Medicine (A Hafiz PhD), Umm AL Qura University, Makkah, Saudi Arabia; Department of Family and Community Medicine (Prof R R Hamadeh PhD), Arabian Gulf University, Manama, Bahrain; School of Health and Environmental Studies (Prof S Hamidi DrPH), Hamdan Bin Mohammed Smart University, Dubai, United Arab Emirates; Department of Public Health (D Handiso MPH), Wachemo University, Hossana, Ethiopia; Medical School (Prof G J Hankey MD), University of Western Australia, Perth, WA, Australia; Department of Neurology (Prof G J Hankey MD), Sir Charles Gairdner Hospital, Perth, WA, Australia; Carlos III Health Institute (Prof R Tabarés-Seisdedos PhD), Biomedical Research Networking Center for Mental Health Network (CiberSAM), Barcelona, Spain (J M Haro MD); Department of Zoology and Entomology (A I Hasaballah PhD), Al Azhar University, Cairo, Egypt; Institute for Social Science Research (M Hasan MPH), ARC Centre of Excellence for Children and Families over the Life Course (M Hasan MPH), School of Dentistry (R Lalloo PhD), The University of Queensland, Brisbane, QLD, Australia; Center for International Health (CIH) and Bergen Center for Ethics and Priority Setting (BCEPS) (S Hassan MPhil), Department of Global Public Health and Primary Care (Prof O F Norheim PhD), Department of Psychosocial Science (Prof S Øverland PhD), University of Bergen, Bergen, Norway; Gastrointestinal and Liver Diseases Research Center (S Hassanipour PhD, F Joukar PhD), Caspian Digestive Disease Research Center (S Hassanipour PhD, F Joukar PhD), Department of Environmental Health Engineering (J Jaafari PhD), Guilan University of Medical Sciences, Rasht, Iran; Independent Consultant, Tabriz, Iran (H Hassankhani PhD); Skaane University Hospital (R J Havmoeller PhD), Skaane County Council, Malmoe, Sweden; Institute of Pharmaceutical Sciences (K Hayat MS), University of Veterinary and Animal Sciences, Lahore, Pakistan; Department of Pharmacy Administration and Clinical Pharmacy (K Hayat MS), Xian Jiaotong University, Xian, China; Independent Consultant, Santa Clara, CA, USA (G Heidari MD); School of Business (Prof C Herteliu PhD), London South Bank University, London, UK; Department for Health (T R Hird PhD), Department of Mathematical Sciences (P Moraga PhD), University of Bath, Bath, UK; Department of Pediatrics (M K Hole MD), University of Texas Austin, Austin, TX, USA; Independent Consultant, Virginia Beach, VA, USA (K P Hopf MPH); Metrics and Evaluation (K P Hopf MPH), Operation Smile, Virginia Beach, VA, USA; Department of Pulmonology (N Horita PhD), Yokohama City University, Yokohama, Japan; National Human Genome Research Institute (NHGRI) (N Horita PhD), Center for Translation Research and Implementation Science (G A Mensah MD), National Institutes of Health, Bethesda, MD, USA; Department of Pharmacology (N Hossain MPhil), Bangladesh Industrial Gases Limited, Tangail, Bangladesh; Institute of Research and Development (M Hosseinzadeh PhD), Institute for Global Health Innovations (C T Nguyen MPH, D N Nguyen MA, H L T Nguyen MPH), Faculty of Pharmacy (D N Nguyen MA), Duy Tan University, Da Nang, Vietnam; Clinical Legal Medicine Department (S Hostiuc PhD), National Institute of Legal Medicine Mina Minovici, Bucharest, Romania; Division of Information and Computing Technology (Prof M Househ PhD), Hamad Bin Khalifa University, Doha, Qatar; Department of Health Services Administration (V Hsieh PhD), Department of Occupational Safety and Health (Prof B Hwang PhD), China Medical University, Taichung, Taiwan; Department of Epidemiology and Health Statistics (Prof G Hu PhD), Central South University, Changsha, China; School of Public Health (T M Huda PhD), Sydney Medical School (S Islam PhD), Asbestos Diseases Research Institute (J Leigh MD), Institute of Bone and Joint Research (IBJR) (E U R Smith PhD), Pain Management Research Institute (PMRI) (E U R Smith PhD), University of Sydney, Sydney, NSW, Australia; Maternal and Child Health Division (T M Huda PhD, S Zaman MPH), International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh; Department of Public Health and Community Medicine (Prof A Humayun PhD), Shaikh Khalifa Bin Zayed Al-Nahyan Medical College, Lahore, Pakistan; International Center for Nutrition and Information (N Ikeda PhD), National Institutes of Biomedical Innovation, Health and Nutrition, Tokyo, Japan; Faculty of Medicine (I M Ilic PhD, Prof M M Santric-Milicevic PhD), School of Public Health and Health Management (Prof M M Santric-Milicevic PhD), University of Belgrade, Belgrade, Serbia; Department of Epidemiology (Prof M D Ilic PhD), Department of Global Health, Economics and Policy (Prof M Jakovljevic PhD), University of Kragujevac, Kragujevac, Serbia; Division of Community Health and Family Medicine (L R Inbaraj MD), Bangalore Baptist Hospital, Bangalore, India; College of Public Health (U Iqbal PhD), Taipei Medical University, Taipei, Taiwan; Research Institute for Endocrine Sciences (S N Irvani MD), School of Management and Medical Education (N Jahanmehr PhD), Safety Promotion and Injury Prevention Research Center (N Jahanmehr PhD), Department of Epidemiology (S Sabour PhD), Injury Prevention and Safety Promotion Research Center (T Yousefinezhadi PhD), Shahid Beheshti University of Medical Sciences, Tehran, Iran (M Khayamzadeh MD); Institute for Physical Activity and Nutrition (S Islam PhD, R Uddin PhD), Department of Psychology (M A Stokes PhD), Deakin University, Burwood, VIC, Australia; Surveillance and Health Services Research (F Islami PhD), American Cancer Society, Atlanta, GA, USA; Department of Social Medicine (Prof H Iso MD), Graduate School of Medicine (Prof K Yamagishi MD), Osaka University, Suita-city, Japan; Department of Biochemistry and Microbiology (C C D Iwu MSc), University of Fort Hare, Alice, South Africa; Grants, Innovation and Product Development Unit (P W Mahasha PhD), South African Medical Research Council, Cape Town, South Africa (C J Iwu PhD, C A Nnaji MPH); Health Informatic Lab (T Javaheri PhD), Department of Computer Science (R Rawassizadeh PhD), Boston University, Boston, MA, USA; Postgraduate Institute of Medicine (A U Jayatilleke PhD), University of Colombo, Colombo, Sri Lanka; Faculty of Graduate Studies (A U Jayatilleke PhD), Institute for Violence and Injury Prevention, Colombo, Sri Lanka; Department of Community Medicine (R P Jha MSc), Dr. Baba Saheb Ambedkar Medical College & Hospital, Delhi, India; Department of Community Medicine (R P Jha MSc), Banaras Hindu University, Varanasi, India; Environmental Research Center (J S Ji DSc), Duke Kunshan University, Kunshan, China; Nicholas School of the Environment (J S Ji DSc), Department of Family Medicine and Community Health (Y Yano MD), Duke Global Health Institute (S Zadey MS), Duke University, Durham, NC, USA; Department of Earth Observation Science (P Jia PhD), University of Twente, Enschede, Netherlands; Beijing Institute of Ophthalmology (Prof J B Jonas MD), Beijing Tongren Hospital, Beijing, China; Department of Family Medicine and Public Health (J J Jozwiak PhD), University of Opole, Opole, Poland; Institute of Family Medicine and Public Health (M Jürisson PhD), University of Tartu, Tartu, Estonia; School of Public Health (Z Kabir PhD), University College Cork, Cork, Ireland; Institute for Prevention of Non-communicable Diseases (R Kalhor PhD), Health Services Management Department (R Kalhor PhD), Qazvin University of Medical Sciences, Qazvin, Iran; Department of Health Management and System Sciences (S M Karimi PhD), University of Louisville, Louisville, KY, USA; Center for Health Equity (S M Karimi PhD), Louisville Metro Department of Public Health & Wellness, Louisville, KY, USA; MRC/CSO Social and Public Health Sciences Unit (S V Katikireddi PhD), University of Glasgow, Glasgow, UK; International Research Center of Excellence (G A Kayode PhD), Institute of Human Virology Nigeria, Abuja, Nigeria; Julius Centre for Health Sciences and Primary Care (G A Kayode PhD), Utrecht University, Utrecht, Netherlands; Open, Distance and eLearning Campus (Prof P N Keiyoro PhD), Department of Psychiatry (M Kumar PhD), School of Economics (M K Muriithi PhD), School of Public Health (R G Wamai PhD), University of Nairobi, Nairobi, Kenya; Department of Public Health (Prof Y S Khader PhD), Jordan University of Science and Technology, Irbid, Jordan; Department of Epidemiology and Biostatistics (E A Khan MPH), Health Services Academy, Islamabad, Pakistan; Department of Health Policy and Management (Prof Y Khang MD), Institute of Health Policy and Management (Prof Y Khang MD), Seoul National University, Seoul, South Korea; Faculty of Health and Wellbeing (K Khatab PhD), Sheffield Hallam University, Sheffield, UK; College of Arts and Sciences (K Khatab PhD), Ohio University, Zanesville, OH, USA; The Iranian Academy of Medical Sciences, Tehran, Iran (M Khayamzadeh MD); Department of Nutrition and Health Science (Prof J Khubchandani PhD), Ball State University, Muncie, IN, USA; Department of Preventive Medicine (Y Kim PhD), Korea University, Seoul, South Korea; School of Traditional Chinese Medicine (Y Kim PhD), Xiamen University Malaysia, Sepang, Malaysia; Department of Nutrition (R W Kimokoti MD), Simmons University, Boston, MA, USA; Faculty of Health (Y Kinfu PhD), University of Canberra, Canberra, ACT, Australia; College of Medicine (Y Kinfu PhD), Qatar University, Doha, Qatar; School of Health Sciences (Prof A Kisa PhD), Kristiania University College, Oslo, Norway; Global Community Health and Behavioral Sciences (Prof A Kisa PhD), Tulane University, New Orleans, LA, USA; Department of Health Economics and Social Security (K Kissimova-Skarbek PhD), Jagiellonian University Medical College, Krakow, Poland; Department of Epidemiology and Public Health (Prof M Kivimäki PhD), Division of Psychology and Language Sciences (M Kumar PhD), University College London, London, UK; Department of Public Health (Prof M Kivimäki PhD), University of Helsinki, Helsinki, Finland (T J Meretoja MD); Public Health Sciences Division (J M Kocarnik PhD), Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Global Healthcare Consulting, New Delhi, India (S Kochhar MD); Arthritis Research Canada, Richmond, BC, Canada (J A Kopec PhD); Federal Research Institute for Health Organization and Informatics of the Ministry of Health (FRIHOI), Moscow, Russia (A V Korotkova PhD); Independent Consultant, Jakarta, Indonesia (S Kosen MD); Department of Global Health (A Kotlo MS), Vancouver Virology Centre, Vancouver, BC, Canada; Department of Internal and Pulmonary Medicine (Prof P A Koul MD), Sheri Kashmir Institute of Medical Sciences, Srinagar, India; Biomedical Research Networking Center for Mental Health Network (CIBERSAM) (A Koyanagi MD), San Juan de Dios Sanitary Park, Sant Boi de Llobregat, Spain; Department of Anthropology (K Krishan PhD), Panjab University, Chandigarh, India; Faculty of Public Health (D Kusuma DSc), University of Indonesia, Depok, Indonesia; Nuffield Department of Population Health (B Lacey PhD), The George Institute for Global Health (Prof S Yaya PhD), Nuffield Department of Medicine (Y Zhao MPH), University of Oxford, Oxford, UK; National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Oxford, UK (B Lacey PhD); Unit of Genetics and Public Health (Prof I Landires MD), Unit of Microbiology and Public Health (V Nunez-Samudio PhD), Institute of Medical Sciences, Las Tablas, Panama; Department of Public Health (V Nunez-Samudio PhD), Ministry of Health, Herrera, Panama (Prof I Landires MD); Medical Director (Prof V C Lansingh PhD), HelpMeSee, New York, NY, USA; General Director (Prof V C Lansingh PhD), Mexican Institute of Ophthalmology, Queretaro, Mexico; Department of Medical Sciences (Prof A O Larsson PhD), Uppsala University, Uppsala, Sweden; Department of Clinical Chemistry and Pharmacology (Prof A O Larsson PhD), Uppsala University Hospital, Uppsala, Sweden; Department of Otorhinolaryngology (S Lasrado MS), Father Muller Medical College, Mangalore, India; Institute of Clinical Physiology (P Lauriola MD), National Research Council, Pisa, Italy; Barcelona Institute for Global Health, Barcelona, Spain (Prof J V Lazarus PhD); School of Pharmacy (S W H Lee PhD), Monash University, Selangor, Malaysia; School of Pharmacy (S W H Lee PhD), Taylor's University Lakeside Campus, Subang Jaya, Malaysia; Neurology, Public Health and Disability Unit (M Leonardi MD, A Raggi PhD, D Sattin PsyD, S Schiavolin MSc), Carlo Besta Neurological Institute IRCCS, Milan, Italy; Department of Medicine (L Lim MRCP), University of Malaya, Kuala Lumpur, Malaysia; Department of Medicine and Therapeutics (L Lim MRCP), The Chinese University of Hong Kong, Shatin, NT, China; Department of Systems, Populations, and Leadership (X Liu PhD), University of Michigan, Ann Arbor, MI, USA; Department of Basic Medical Sciences, Neuroscience and Sense Organs (Prof G Logroscino PhD), University of Bari Aldo Moro, Bari, Italy; Department of Clinical Research in Neurology (Prof G Logroscino PhD), Fondazione Cardinale Giovanni Panico Hospital, Tricase, Italy; Radiology and Precision Health Program (M Mahmoudi PhD), Michigan State University, East Lansing, MI, USA; Faculty of Medicine (J N Malagón-Rojas MSc), El Bosque University, Bogota, Colombia; Faculty of Public Health (S Martini PhD), Airlangga University, Surabaya, Indonesia; Indonesian Public Health Association, Surabaya, Indonesia (S Martini PhD); Campus Caucaia (F R Martins-Melo PhD), Federal Institute of Education, Science and Technology of Ceará, Caucaia, Brazil; Institute of Population Health Sciences (M R Mathur PhD), University of Liverpool, Liverpool, UK; Department of Ophthalmology (C McAlinden PhD), Singleton Hospital, Swansea, UK; Academic Area of Dentistry (C E Medina-Solís MSc), Autonomous University of Hidalgo State, Pachuca, Mexico; Department of Pharmacy (B Meharie MSc), Wollo University, Dessie, Ethiopia; Neurology Department (Prof M Mehndiratta MD), Janakpuri Super Specialty Hospital Society, New Delhi, India; Department of Neurology (Prof M Mehndiratta MD), Govind Ballabh Institute of Medical Education and Research, New Delhi, India; Department of Nutrition (T Mekonnen MPH), University of Oslo, Oslo, Norway; Institute of Human Virology (P T N Memiah DrPH), University of Maryland, Baltimore, MD, USA; Peru Country Office (W Mendoza MD), United Nations Population Fund (UNFPA), Lima, Peru; Neurology Unit (A Meretoja MD), Breast Surgery Unit (T J Meretoja MD), Helsinki University Hospital, Helsinki, Finland; Clinical Microbiology and Parasitology Unit (T Mestrovic PhD), Dr. Zora Profozic Polyclinic, Zagreb, Croatia; University Centre Varazdin (T Mestrovic PhD), University North, Varazdin, Croatia; Center for Innovation in Medical Education (B Miazgowski MD), Pomeranian Medical University, Szczecin, Poland (B Miazgowski MD); Department of Women-Mother-Child (I Michalek PhD), Vaud University Hospital Center, Lausanne, Switzerland; Internal Medicine Programme (Prof E M Mirrakhimov PhD), Kyrgyz State Medical Academy, Bishkek, Kyrgyzstan; Department of Atherosclerosis and Coronary Heart Disease (Prof E M Mirrakhimov PhD), National Center of Cardiology and Internal Disease, Bishkek, Kyrgyzstan; Institute of Addiction Research (ISFF) (B Moazen MSc), Frankfurt University of Applied Sciences, Frankfurt, Germany; Department of Epidemiology and Biostatistics (A Mohammadian-Hafshejani PhD), Shahrekord University of Medical Sciences, Shahrekord, Iran; Department of Public Health (J A Mohammed MPH), Samara University, Semera, Ethiopia; Health Systems and Policy Research Unit (S Mohammed PhD), Department of Community Medicine (M B Sufiyan MD), Ahmadu Bello University, Zaria, Nigeria; Clinical Epidemiology and Public Health Research Unit (L Monasta DSc, L Ronfani PhD), Burlo Garofolo Institute for Maternal and Child Health, Trieste, Italy; Department of Biomedical and Dental Sciences and Morphofunctional Imaging (Prof S Mondello MD), Messina University, Messina, Italy; Department of Food Science (Prof A Mousavi Khaneghah PhD), University of Campinas (Unicamp), Campinas, Brazil; Department of Pediatric Medicine (Prof G Mustafa MD), The Children's Hospital & The Institute of Child Health, Multan, Pakistan; Department of Pediatrics & Pediatric Pulmonology (Prof G Mustafa MD), Institute of Mother & Child Care, Multan, Pakistan; Knowledge Translation and Utilization Unit (Prof A F Nabhan PhD), Egyptian Center for Evidence Based Medicine, Cairo, Egypt; Research and Analytics Department (A J Nagarajan MTech), Initiative for Financing Health and Human Development, Chennai, India; Department of Research and Analytics (A J Nagarajan MTech), Bioinsilico Technologies, Chennai, India; Laboratory of Public Health Indicators Analysis and Health Digitalization (M Naimzada MD, N Otstavnov BA, S S Otstavnov PhD, M V Titova PhD), Moscow Institute of Physics and Technology, Dolgoprudny, Russia; Experimental Surgery and Oncology Laboratory (M Naimzada MD), Kursk State Medical University, Kursk, Russia; Suraj Eye Institute, Nagpur, India (V Nangia MD); Department for the Control of Disease, Epidemics, and Pandemics (J Nansseu MD), Ministry of Public Health, Yaoundé, Cameroon; Department of Public Heath (J Nansseu MD), Department of Public Health (G Nguefack-Tsague PhD), University of Yaoundé I, Yaoundé, Cameroon; Disease Control and Environmental Health (R Ndejjo MSc), Makerere University, Kampala, Uganda; Department of General Surgery (I Negoi PhD), Emergency Hospital of Bucharest, Bucharest, Romania; Cardio-Aid, Bucharest, Romania (R I Negoi PhD); Department of Health Sciences (S Neupane PhD), University of Tampere, Tampere, Finland; Research & Statistics Unit (K N Ngari MSc), Synotech Consultants, Nairobi, Kenya; Department of Biological Sciences (J W Ngunjiri DrPH), University of Embu, Embu, Kenya; Department of Health Policy and Management (S Nomura PhD), Keio University, Tokyo, Japan; Department of Global Health Policy (S Nomura PhD), University of Tokyo, Tokyo, Japan; Translational Health Research Institute (F A Ogbo PhD, Prof A M N Renzaho PhD), School of Social Sciences and Psychology (Prof A M N Renzaho PhD), Western Sydney University, Sydney, NSW, Australia; Department of Preventive Medicine (I Oh PhD), Kyung Hee University, Dongdaemun-gu, South Korea; Disease Surveillance and Epidemic Response (E W Okunga MSc), Ministry of Health, Nairobi, Kenya; Gorgan Congenital Malformations Research Center (M Oladnabi PhD), Golestan Research Center of Gastroenterology and Hepatology (GRCGH) (G Roshandel PhD), Golestan University of Medical Sciences, Gorgan, Iran; Department of Psychiatry (A T Olagunju MD), University of Lagos, Lagos, Nigeria; Centre for Healthy Start Initiative, Lagos, Nigeria (B O Olusanya PhD, J O Olusanya MBA); Diplomacy and Public Relations Department (A Omar Bali PhD), University of Human Development, Sulaimaniyah, Iraq; Department of Pharmacology and Therapeutics (Prof O E Onwujekwe PhD), University of Nigeria Nsukka, Enugu, Nigeria; Department of Medicine (Prof A Ortiz MD), Princess University Hospital (Prof J B Soriano MD), Autonomous University of Madrid, Madrid, Spain; Department of Nephrology and Hypertension (Prof A Ortiz MD), The Institute for Health Research Foundation Jiménez Díaz University Hospital, Madrid, Spain; Department of Biomedical Sciences (Prof S M Ostojic PhD), University of Novi Sad, Novi Sad, Serbia; Department of Project Management (S S Otstavnov PhD), Department of Health Care Administration and Economics (Prof V Vlassov MD), National Research University Higher School of Economics, Moscow, Russia; Division of Mental and Physical Health (Prof S Øverland PhD), Norwegian Institute of Public Health, Bergen, Norway; Department of Health Metrics (A Pana MD), Center for Health Outcomes & Evaluation, Bucharest, Romania; National Institute of Health Research and Development (H U Pangaribuan MSc), Ministry of Health, Jakarta, Indonesia; Research & Development Department (M Pathak PhD), Kalinga Institute of Medical Sciences, Bhubaneswar, India; Population Health Theme (Prof G C Patton MD), Centre for Adolescent Health (Prof S M Sawyer MD), Critical Care and Neurosciences (Prof R G Weintraub MB), Murdoch Childrens Research Institute, Melbourne, VIC, Australia; Public Health Youth Society of Nepal, Pokhara, Nepal (S Paudel MPH); Public Health Update, Pokhara, Nepal (S Paudel MPH); College of Public Health, Medical, and Veterinary Sciences (A E Peden PhD), James Cook University, Townsville, NSW, Australia; School of Global Public Health (E K Peprah PhD), New York University, New York, NY, USA; Department of Orthopedics (J Pereira MS), Yenepoya Medical College, Mangalore, India; Department of Cardiology (T Pilgrim MD), University of Bern, Bern, Switzerland; HIV and Mental Health Department (K N Pokhrel PhD), Integrated Development Foundation Nepal, Kathmandu, Nepal; Department of Nutrition and Food Sciences (H Pourjafar PhD), Maragheh University of Medical Sciences, Maragheh, Iran; Dietary Supplements and Probiotic Research Center (H Pourjafar PhD), Alborz University of Medical Sciences, Karaj, Iran; Clinical Research Center (S I Prada PhD), Valle del Lili Foundation, Cali, Colombia; Center for Studies in Social Protection and Health Economics (S I Prada PhD), ICESI University, Cali, Colombia; Health Sciences Department (D R A Pribadi MSc), Muhammadiyah University of Surakarta, Sukoharjo, Indonesia; College of Medicine (A Radfar MD), University of Central Florida, Orlando, FL, USA; Department of Medicine (A Rafiee MSc), University of Alberta, Edmonton, AB, Canada; Thalassemia and Hemoglobinopathy Research Center (F Rahim PhD), Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran; School of Nursing and Healthcare Professions (M Rahman PhD), Federation University Australia, Berwick, VIC, Australia; Public Health Department (Prof S M Rana PhD), University of Health Sciences, Lahore, Pakistan; Research Department (C L Ranabhat PhD), Policy Research Institute, Kathmandu, Nepal; Health and Public Policy Department (C L Ranabhat PhD), Global Center for Research and Development, Kathmandu, Nepal; Department of Oral Pathology (S Rao MDS), Srinivas Institute of Dental Sciences, Mangalore, India; University College London Hospitals, London, UK (D L Rawaf MD); Academic Public Health England (Prof S Rawaf MD), Public Health England, London, UK (Prof N Steel PhD); School of Health, Medical and Applied Sciences (L Rawal PhD), CQ University, Sydney, NSW, Australia; School of Nursing and Midwifery (V Renjith PhD), Royal College of Surgeons in Ireland - Bahrain, Muharraq Governorate, Bahrain; Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA) (Prof N Rezaei PhD), Universal Scientific Education and Research Network (USERN), Tehran, Iran; School of Physiotherapy (D C Ribeiro PhD), University of Otago, Dunedin, New Zealand; Department of Surgery (J Rickard MD), University of Minnesota, Minneapolis, MN, USA; Department of Surgery (J Rickard MD), University Teaching Hospital of Kigali, Kigali, Rwanda; Department of Clinical Research (L Roever PhD), Federal University of Uberlândia, Uberlândia, Brazil; Department of Neuroscience (M Romoli MD), University of Perugia, Perugia, Italy; Department of Neurology (M Romoli MD), Rimini “Infermi” Hospital - AUSL Romagna, Rimini, Italy; Agrosavia, Palmira, Colombia (E Rubagotti PhD); Department of Internal Medicine (G M Rwegerera MD), University of Botswana, Gaborone, Botswana; Neuropsychiatric Institute (Prof P S Sachdev MD), Prince of Wales Hospital, Randwick, NSW, Australia; Department of Family and Community Medicine (B Saddik PhD), University of Sharjah, Sharjah, United Arab Emirates; Halal Research Center of IRI (A Sahebkar PhD), Food and Drug Administration of the Islamic Republic of Iran, Tehran, Iran; Neurogenic Inflammation Research Center (A Sahebkar PhD), Mashhad University of Medical Sciences, Mashhad, Iran; Department of Phytochemistry (Prof S Sajadi PhD), Soran University, Soran, Iraq; Department of Nutrition (Prof S Sajadi PhD), Cihan University-Erbil, Kurdistan Region, Iraq; Center for Health Policy & Center for Primary Care and Outcomes Research (Prof J A Salomon PhD), Stanford University, Stanford, CA, USA; Department of Surgery (Prof J Sanabria MD), Marshall University, Huntington, WV, USA; Department of Community Medicine (S Y Saraswathy PhD), PSG Institute of Medical Sciences and Research, Coimbatore, India; PSG-FAIMER South Asia Regional Institute, Coimbatore, India (S Y Saraswathy PhD); Faculty of Medicine (Prof R Sarmiento-Suárez MPH), University of Applied and Environmental Sciences, Bogota, Colombia; National School of Public Health (Prof R Sarmiento-Suárez MPH), Carlos III Health Institute, Madrid, Spain; Department of Geriatrics and Long Term Care (B Sathian PhD), Hamad Medical Corporation, Doha, Qatar; Faculty of Health & Social Sciences (B Sathian PhD), Bournemouth University, Bournemouth, UK; GSK Biologicals, Wavre, Belgium (M Savic PhD); Department of Epidemiology (Prof D Saxena PhD), Indian Institute of Public Health, Gandhinagar, India; Unit for Hypertension and Cardiovascular Disease (Prof A E Schutte PhD), North-West University, Potchefstroom, South Africa; The George Institute for Global Health (Prof A E Schutte PhD), University of New South Wales, Sydney, NSW, Australia; Department of Psychology (D C Schwebel PhD), School of Medicine (Prof J A Singh MD), University of Alabama at Birmingham, Birmingham, AL, USA; Oral Diagnosis, Digital Health and Health Services Research (Prof F Schwendicke PhD), Charité University Medical Center Berlin, Berlin, Germany; Center for Biomedical Information Technology (F Sha PhD), Shenzhen Institutes of Advanced Technology, Shenzhen, China; Public Health Division (A A Shaheen PhD), An-Najah National University, Nablus, Palestine; Independent Consultant, Karachi, Pakistan (M A Shaikh MD); Faculty of Caring Science, Work Life, and Social Welfare (M Shamsizadeh MSc), University of Borås, Borås, Sweden; Department of Community Medicine (M Shannawaz PhD), BLDE University, Vijayapur, India; Centre for Medical Informatics (Prof A Sheikh MD), University of Edinburgh, Edinburgh, UK; National Institute of Infectious Diseases, Tokyo, Japan (M Shigematsu PhD); College of Medicine (Prof J Shin MD), Yonsei University, Seoul, South Korea; Finnish Institute of Occupational Health, Helsinki, Finland (R Shiri PhD); Faculty of Dental Sciences (Prof K M Shivakumar PhD), Krishna Institute of Medical Sciences, Karad, India; School of Public Health (K Shuval PhD), University of Haifa, Haifa, Israel; School of Health (S Siabani PhD), University of Technology Sydney, Sydney, NSW, Australia; Medical Research Agency, Warsaw, Poland (R Sierpinski PhD); School of Medicine (R Sierpinski PhD), Cardinal Wyszynski University, Warsaw, Poland; Department of Psychology (Prof I D Sigfusdottir PhD, R Sigurvinsdottir PhD), Reykjavik University, Reykjavik, Iceland; Department of Health and Behavior Studies (Prof I D Sigfusdottir PhD), Columbia University, New York, NY, USA; Department of Physical Education (Prof D A S Silva PhD), Federal University of Santa Catarina, Florianopolis, Brazil; Department of Law, Economics, Management and Quantitative Methods (Prof B Simonetti PhD), University of Sannio, Benevento, Italy; WSB University in Gdańsk, Gdańsk, Poland (Prof B Simonetti PhD); Medicine Service (Prof J A Singh MD), US Department of Veterans Affairs (VA), Birmingham, AL, USA; Department of Humanities and Social Sciences (P Singh MSc), Indian Institute of Technology, Roorkee, Roorkee, India; Department of Epidemiology (D N Sinha PhD), School of Preventive Oncology, Patna, India; Department of Epidemiology (D N Sinha PhD), Healis Sekhsaria Institute for Public Health, Mumbai, India; Department No.16 (V Y Skryabin MD), Laboratory of Genetics and Genomics (Prof M S Zastrozhin PhD), Moscow Research and Practical Centre on Addictions, Moscow, Russia; Nursing Care Research Center (A Soheili PhD), Semnan University of Medical Sciences, Semnan, Iran; Centro de Investigación Biomédica en Red Enfermedades Respiratorias (CIBERES, Center for Biomedical Research in Respiratory Diseases Network), Madrid, Spain (Prof J B Soriano MD); Hull York Medical School (I N Soyiri PhD), University of Hull, Hull City, UK; Division of Community Medicine (C T Sreeramareddy MD), International Medical University, Kuala Lumpur, Malaysia; Department of Primary Care and Public Health (Prof N Steel PhD), University of East Anglia, Norwich, UK; Pediatric Services (I Sultan MD), King Hussein Cancer Center, Amman, Jordan; Pediatrics Department (I Sultan MD), University of Jordan, Amman, Jordan; Minister of Health (L Szumowski MD), Institute of Cardiology, Warsaw, Poland; Department of Medicine (Prof R Tabarés-Seisdedos PhD), University of Valencia, Valencia, Spain; Cancer Control Center (T Tabuchi MD), Osaka International Cancer Institute, Osaka, Japan; School of Dentistry and Oral Health (S K Tadakamadla PhD), Griffith University, Gold Coast, QLD, Australia; Department of Pharmacy (B W Taddele MPH), Arbaminch College of Health Sciences, Arbaminch, Ethiopia; Africa Health Research Institute, Berea, South Africa (Prof F C Tanser PhD); Department of Population Science and Human Resource Development (Prof M I Tareque PhD), University of Rajshahi, Rajshahi, Bangladesh; Research and Development Center for Humanities and Health Management (I U Tarigan PhD), National Institute of Health Research & Development, Jakarta, Indonesia; University of Basel, Basel, Switzerland (F Tediosi PhD); Division of Biostatistics and Epidemiology (B Thakur PhD), Texas Tech University, El Paso, TX, USA; Timiryazev Institute of Plant Physiology (M V Titova PhD), Russian Academy of Sciences, Moscow, Russia; Department of Medicine (Prof M Tonelli MD), University of Calgary, Calgary, AB, Canada; Institute of Public Health (R Topor-Madry PhD), Jagiellonian University Medical College, Kraków, Poland; Agency for Health Technology Assessment and Tariff System, Warsaw, Poland (R Topor-Madry PhD); Modestum LTD, London, UK (M R Tovani-Palone PhD); Department of Health Economics (B X Tran PhD), Hanoi Medical University, Hanoi, Vietnam; Lee Kong Chian School of Medicine (L Tudor Car PhD), Nanyang Technological University, Singapore, Singapore; Department of Microbiology (I Ullah PhD), Iqra National University, Peshawar, Pakistan; TB Culture Laboratory (I Ullah PhD), Mufti Mehmood Memorial Teaching Hospital, Dera Ismail Khan, Pakistan; Department of Community Medicine (C D Umeokonkwo MPH), Alex Ekwueme Federal University Teaching Hospital Abakaliki, Abakaliki, Nigeria; Amity Institute of Biotechnology (E Upadhyay PhD), Amity University Rajasthan, Jaipur, India; Velez Sarsfield Hospital, Buenos Aires, Argentina (Prof P R Valdez MEd); Department of Nephrology (Prof S Varughese FRCP), Christian Medical College and Hospital (CMC), Vellore, India; UKK Institute, Tampere, Finland (Prof T J Vasankari MD); Raffles Neuroscience Centre (Prof N Venketasubramanian MBBS), Raffles Hospital, Singapore, Singapore; Yong Loo Lin School of Medicine (Prof N Venketasubramanian MBBS), National University of Singapore, Singapore, Singapore; Occupational Health Unit (Prof F S Violante MD), Sant'Orsola Malpighi Hospital, Bologna, Italy; Foundation University Medical College (Prof Y Waheed PhD), Foundation University Islamabad, Islamabad, Pakistan; Cultures, Societies and Global Studies, & Integrated Initiative for Global Health (R G Wamai PhD), Northeastern University, Boston, MA, USA; Cardiology Department (Prof R G Weintraub MB), Royal Children's Hospital, Melbourne, VIC, Australia; Leonard Davis Institute of Health Economics (J Weiss MA), Population Studies Center (J Weiss MA), University of Pennsylvania, Philadelphia, PA, USA; Demographic Change and Aging Research Area (A Werdecker PhD), Competence Center of Mortality-Follow-Up of the German National Cohort (R Westerman DSc), Federal Institute for Population Research, Wiesbaden, Germany; NIHR Biomedical Research Centre (Prof C D A Wolfe MD), Guy's and St.Thomas' Hospital and Kings College London, London, UK; Department of Orthopaedics (Prof A Wu MD), Wenzhou Medical University, Wenzhou, China; Department of Behavior and Operation Management (Y Xie MD), Beijing Advanced Innovation Center for Big Data-based Precision Medicine, Beijing, China; Clinical Cancer Research Center (S Yahyazadeh Jabbari MD), Milad General Hospital, Tehran, Iran; Research and Development Center for Health Services (Prof K Yamagishi MD), University of Tsukuba, Tsukuba, Japan; School of International Development and Global Studies (Prof S Yaya PhD), University of Ottawa, Ottawa, ON, Canada; Department of Neuropsychopharmacology (N Yonemoto MPH), National Center of Neurology and Psychiatry, Kodaira, Japan; Department of Public Health (N Yonemoto MPH), Juntendo University, Tokyo, Japan; Department of Health Policy and Management (Prof M Z Younis PhD), Jackson State University, Jackson, MS, USA; School of Medicine (Prof M Z Younis PhD), Tsinghua University, Beijing, China; Department of Health care Management and Economics (H Yusefzadeh PhD), Urmia University of Medical Science, Urmia, Iran; Department of Pharmaceutics (S Zaidi PhD), Dow University of Health Sciences, Karachi, Pakistan; Addictology Department (Prof M S Zastrozhin PhD), Russian Medical Academy of Continuous Professional Education, Moscow, Russia; School of Public Health (Y Zhang PhD), Hubei Province Key Laboratory of Occupational Hazard Identification and Control (Y Zhang PhD), Wuhan University of Science and Technology, Wuhan, China; School of Biology and Pharmaceutical Engineering (X G Zhao PhD), Wuhan Polytechnic University, Wuhan, China; School of Health Sciences (X G Zhao PhD), Wuhan University, Wuhan, China; Department of Epidemiology, Human Genetics, and Environmental Sciences (C Zhu MPH), University of Texas Health Science Center at Houston, Houston, TX, USA.Declaration of interestsAli Almasi reports a patent null pending. Robert Ancuceanu reports receiving consultancy and speakers' fees from various pharmaceutical companies. Ettore Beghi reports grants from the Italian Ministry of Health, grants from SOBI, and personal fees from Arvelle Therapeutics, outside the submitted work. Hanne Christensen reports personal fees from Bristol-Myers Squibb, Bayer, Boehringer-Ingelheim, outside the submitted work. Vivekanand Jha reports grants from GlaxoSmithKline, grants from Baxter Healthcare, personal fees from NephroPlus, grants from Biocon, grants from Zydus Cadilla, outside the submitted work. Jacek Jerzy Jozwiak reports personal fees from Amgen, Alab, Teva, Synexus, and Boehringer Ingelheim, outside the submitted work. Srinivasa Vittal Katikireddi reports support from the Medical Research Council and from the Scottish Government Chief Scientist Office, during the conduct of the study. Walter Mendoza is Program Analyst in Population and Development at the United Nations Population Fund-UNFPA Country Office in Peru, an institution which does not necessarily endorse this study. Jonathan F Mosser reports grants from the Bill and Melinda Gates Foundation, during the conduct of the study. Shuhei Nomura reports grants from the Ministry of Education, Culture, Sports, Science, and Technology of Japan. Thomas Pilgrim reports grants and personal fees from Biotronik and Boston Scientific, grants from Edwards Lifesciences, and personal fees from HighLife SAS for his work as a member of clinical event committee for a study sponsored by HighLife Sas, outside the submitted work. Maarten J Postma reports grants and personal fees from MSD, GlaxoSmithKline, Pfizer, Boehringer Ingelheim, Novavax, Bristol-Myers Squibb, AstraZeneca, Sanofi, IQVIA, and Seqirus; personal fees from Quintiles, Novartis, and Pharmerit; 2% of stocks from Ingress Health, 100% of stocks from PAG, being an advisor to Asc Academics; and grants from Bayer, BioMerieux, WHO, the EU, FIND, Antilope, DIKTI, LPDP, and Budi, outside the submitted work. Elisabetta Pupillo reports grants from AIFA, outside the submitted work. Miloje Savic is an employee of GlaxoSmithKline Biologicals, Wavre, Belgium, and holds GlaxoSmithKline restricted shares. Aletta Elisabeth Schutte reports personal fees from Omron Healthcare, Servier, Novartis, Takeda, and Abbott, outside the submitted work. Mark G Shrime reports grants from Mercy Ships and Damon Runyon Cancer Research Foundation, outside the submitted work. Jasvinder A Singh reports personal fees from Crealta/Horizon, Medisys, Fidia, UBM LLC, Trio health, Medscape, WebMD, Clinical Care options, Clearview healthcare partners, Putnam associates, Spherix, Practice Point communications, the National Institutes of Health and the American College of Rheumatology; personal fees from Simply Speaking, holding stock in Amarin pharmaceuticals and Viking pharmaceuticals, non-financial support from the FDA Arthritis Advisory Committee, non-financial support from Steering committee of OMERACT, an international organization that develops measures for clinical trials and receives arm's length funding from 12 pharmaceutical companies, non-financial support from the Veterans Affairs Rheumatology Field Advisory Committee, and non-financial support from the Editor and the Director of the UAB Cochrane Musculoskeletal Group Satellite Center on Network Meta-analysis, outside the submitted work. Jeffrey D Stanaway reports grants from the Bill and Melinda Gates Foundation, during the conduct of the study. Fotis Topouzis reports grants from Pfizer, Thea, Rheon, Pharmaten, Bayer, and Bausch & Lomb; and grants and personal fees from Novartis and Omikron, outside the submitted work. Riaz Uddin worked as a visiting fellow at Deakin University Institute for Physical Activity and Nutrition (IPAN), which paid for his travel (including flights and transport), accommodation, and meals from Deakin University, outside the submitted work.Data sharing
To download the data used in these analyses, please visit the Global Health Data Exchange at http://ghdx.healthdata.org/gbd-2019.AcknowledgmentsLucas Guimarães Abreu acknowledges support from Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (Capes) - Finance Code 001, Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) and Fundação de Amparo à Pesquisa do Estado de Minas Gerais (FAPEMIG). Olatunji O Adetokunboh acknowledges South African Department of Science & Innovation, and National Research Foundation. Anurag Agrawal acknowledges support from the Wellcome Trust DBT India Alliance Senior Fellowship IA/CPHS/14/1/501489. Rufus Olusola Akinyemi acknowledges Grant U01HG010273 from the National Institutes of Health (NIH) as part of the H3Africa Consortium. Rufus Olusola Akinyemi is further supported by the FLAIR fellowship funded by the UK Royal Society and the African Academy of Sciences. Syed Mohamed Aljunid acknowledges the Department of Health Policy and Management, Faculty of Public Health, Kuwait University and International Centre for Casemix and Clinical Coding, Faculty of Medicine, National University of Malaysia for the approval and support to participate in this research project. Marcel Ausloos, Claudiu Herteliu, and Adrian Pana acknowledge partial support by a grant of the Romanian National Authority for Scientific Research and Innovation, CNDS-UEFISCDI, project number PN-III-P4-ID-PCCF-2016-0084. Till Winfried Bärnighausen acknowledges support from the Alexander von Humboldt Foundation through the Alexander von Humboldt Professor award, funded by the German Federal Ministry of Education and Research. Juan J Carrero was supported by the Swedish Research Council (2019-01059). Felix Carvalho acknowledges UID/MULTI/04378/2019 and UID/QUI/50006/2019 support with funding from FCT/MCTES through national funds. Vera Marisa Costa acknowledges support from grant (SFRH/BHD/110001/2015), received by Portuguese national funds through Fundação para a Ciência e a Tecnologia (FCT), IP, under the Norma TransitĀ3ria DL57/2016/CP1334/CT0006. Jan-Walter De Neve acknowledges support from the Alexander von Humboldt Foundation. Kebede Deribe acknowledges support by Wellcome Trust grant number 201900/Z/16/Z as part of his International Intermediate Fellowship. Claudiu Herteliu acknowledges partial support by a grant co-funded by European Fund for Regional Development through Operational Program for Competitiveness, Project ID P_40_382. Praveen Hoogar acknowledges the Centre for Bio Cultural Studies (CBiCS), Manipal Academy of Higher Education(MAHE), Manipal and Centre for Holistic Development and Research (CHDR), Kalghatgi. Bing-Fang Hwang acknowledges support from China Medical University (CMU108-MF-95), Taichung, Taiwan. Mihajlo Jakovljevic acknowledges the Serbian part of this GBD contribution was co-funded through the Grant OI175014 of the Ministry of Education Science and Technological Development of the Republic of Serbia. Aruna M Kamath acknowledges funding from the National Institutes of Health T32 grant (T32GM086270). Srinivasa Vittal Katikireddi acknowledges funding from the Medical Research Council (MC_UU_12017/13 & MC_UU_12017/15), Scottish Government Chief Scientist Office (SPHSU13 & SPHSU15) and an NRS Senior Clinical Fellowship (SCAF/15/02). Yun Jin Kim acknowledges support from the Research Management Centre, Xiamen University Malaysia (XMUMRF/2018-C2/ITCM/0001). Kewal Krishan acknowledges support from the DST PURSE grant and UGC Center of Advanced Study (CAS II) awarded to the Department of Anthropology, Panjab University, Chandigarh, India. Manasi Kumar acknowledges support from K43 TW010716 Fogarty International Center/NIMH. Ben Lacey acknowledges support from the NIHR Oxford Biomedical Research Centre and the BHF Centre of Research Excellence, Oxford. Iván Landires is a member of the Sistema Nacional de InvestigaciĀ3n (SNI), which is supported by the Secretaría Nacional de Ciencia Tecnología e Innovación (SENACYT), Panamá. Jeffrey V Lazarus acknowledges support by a Spanish Ministry of Science, Innovation and Universities Miguel Servet grant (Instituto de Salud Carlos III/ESF, European Union [CP18/00074]). Peter T N Memiah acknowledges CODESRIA; HISTP. Subas Neupane acknowledges partial support from the Competitive State Research Financing of the Expert Responsibility area of Tampere University Hospital. Shuhei Nomura acknowledges support from the Ministry of Education, Culture, Sports, Science, and Technology of Japan (18K10082). Alberto Ortiz acknowledges support by ISCIII PI19/00815, DTS18/00032, ISCIII-RETIC REDinREN RD016/0009 Fondos FEDER, FRIAT, Comunidad de Madrid B2017/BMD-3686 CIFRA2-CM. These funding sources had no role in the writing of the manuscript or the decision to submit it for publication. George C Patton acknowledges support from a National Health & Medical Research Council Fellowship. Marina Pinheiro acknowledges support from FCT for funding through program DL 57/2016 - Norma transitĀ3ria. Alberto Raggi, David Sattin, and Silvia Schiavolin acknowledge support by a grant from the Italian Ministry of Health (Ricerca Corrente, Fondazione Istituto Neurologico C Besta, Linea 4 - Outcome Research: dagli Indicatori alle Raccomandazioni Cliniche). Daniel Cury Ribeiro acknowledges support from the Sir Charles Hercus Health Research Fellowship - Health Research Council of New Zealand (18/111). Perminder S Sachdev acknowledges funding from the NHMRC Australia. Abdallah M Samy acknowledges support from a fellowship from the Egyptian Fulbright Mission Program. Milena M Santric-Milicevic acknowledges support from the Ministry of Education, Science and Technological Development of the Republic of Serbia (Contract No. 175087). Rodrigo Sarmiento-Suárez acknowledges institutional support from University of Applied and Environmental Sciences in Bogota, Colombia, and Carlos III Institute of Health in Madrid, Spain. Maria Inês Schmidt acknowledges grants from the Foundation for the Support of Research of the State of Rio Grande do Sul (IATS and PrInt) and the Brazilian Ministry of Health. Sheikh Mohammed Shariful Islam acknowledges a fellowship from the National Heart Foundation of Australia and Deakin University. Aziz Sheikh acknowledges support from Health Data Research UK. Kenji Shibuya acknowledges Japan Ministry of Education, Culture, Sports, Science and Technology. Joan B Soriano acknowledges support by Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III (ISCIII), Madrid, Spain. Rafael Tabarés-Seisdedos acknowledges partial support from grant PI17/00719 from ISCIII-FEDER. Santosh Kumar Tadakamadla acknowledges support from the National Health and Medical Research Council Early Career Fellowship, Australia. Marcello Tonelli acknowledges the David Freeze Chair in Health Services Research at the University of Calgary, AB, Canada.Editorial note: the Lancet Group takes a neutral position with respect to territorial claims in published maps and institutional affiliations.Supplementary Materials
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Published: August 27, 2020DOI: https://doi.org/10.1016/S0140-6736(20)30750-9
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Open AccessGlobal Burden of DiseaseThe Global Burden of Disease study provides the most comprehensive global health estimates, examining worldwide, national, and regional trends for mortality and morbidity from major diseases, injuries, and risk factors to understand the health challenges of the 21st century.
