Measuring universal health coverage based on an index of effective coverage of health services in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019

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

Ion cyclotron resonance heating for tungsten control in various JET H-mode scenarios

Ion cyclotron resonance heating (ICRH) in the hydrogen minority scheme provides central ion heating and acts favorably on the core tungsten transport. Full wave modeling shows that, at medium power level (4 MW), after collisional redistribution, the ratio of power transferred to the ions and the electrons vary little with the minority (hydrogen) concentration n H/n e but the high-Z impurity screening provided by the fast ions temperature increases with the concentration. The power radiated by tungsten in the core of the JET discharges has been analyzed on a large database covering the 2013-2014 campaign. In the baseline scenario with moderate plasma current (I p = 2.5 MA) ICRH modifies efficiently tungsten transport to avoid its accumulation in the plasma centre and, when the ICRH power is increased, the tungsten radiation peaking evolves as predicted by the neo-classical theory. At higher current (3-4 MA), tungsten accumulation can be only avoided with 5 MW of ICRH power with high gas injection rate. For discharges in the hybrid scenario, the strong initial peaking of the density leads to strong tungsten accumulation. When this initial density peaking is slightly reduced, with an ICRH power in excess of 4 MW,very low tungsten concentration in the core (∼10-5) is maintained for 3 s. MHD activity plays a key role in tungsten transport and modulation of the tungsten radiation during a sawtooth cycle is correlated to the fishbone activity triggered by the fast ion pressure gradient

Calculations to support JET neutron yield calibration: Modelling of neutron emission from a compact DT neutron generator

At the Joint European Torus (JET) the ex-vessel fission chambers and in-vessel activation detectors are used as the neutron production rate and neutron yield monitors respectively. In order to ensure that these detectors produce accurate measurements they need to be experimentally calibrated. A new calibration of neutron detectors to 14 MeV neutrons, resulting from deuterium–tritium (DT) plasmas, is planned at JET using a compact accelerator based neutron generator (NG) in which a D/T beam impinges on a solid target containing T/D, producing neutrons by DT fusion reactions. This paper presents the analysis that was performed to model the neutron source characteristics in terms of energy spectrum, angle–energy distribution and the effect of the neutron generator geometry. Different codes capable of simulating the accelerator based DT neutron sources are compared and sensitivities to uncertainties in the generator's internal structure analysed. The analysis was performed to support preparation to the experimental measurements performed to characterize the NG as a calibration source. Further extensive neutronics analyses, performed with this model of the NG, will be needed to support the neutron calibration experiments and take into account various differences between the calibration experiment and experiments using the plasma as a source of neutrons

3D simulations of gas puff effects on edge plasma and ICRF coupling in JET

Recent JET (ITER-Like Wall) experiments have shown that the fueling gas puffed from different locations of the vessel can result in different scrape-off layer (SOL) density profiles and therefore different radio frequency (RF) coupling. To reproduce the experimental observations, to understand the associated physics and to optimize the gas puff methods, we have carried out three-dimensional (3D) simulations with the EMC3-EIRENE code in JET-ILW including a realistic description of the vessel geometry and the gas injection modules (GIMs) configuration. Various gas puffing methods have been investigated, in which the location of gas fueling is the only variable parameter. The simulation results are in quantitative agreement with the experimental measurements. They confirm that compared to divertor gas fueling, mid-plane gas puffing increases the SOL density most significantly but locally, while top gas puffing increases it uniformly in toroidal direction but to a lower degree. Moreover, the present analysis corroborates the experimental findings that combined gas puff scenarios - based on distributed main chamber gas puffing - can be effective in increasing the RF coupling for multiple antennas simultaneously. The results indicate that the spreading of the gas, the local ionization and the transport of the ionized gas along the magnetic field lines connecting the local gas cloud in front of the GIMs to the antennas are responsible for the enhanced SOL density and thus the larger RF coupling

Five insights from the Global Burden of Disease Study 2019

The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 provides a rules-based synthesis of the available evidence on levels and trends in health outcomes, a diverse set of risk factors, and health system responses. GBD 2019 covered 204 countries and territories, as well as first administrative level disaggregations for 22 countries, from 1990 to 2019. Because GBD is highly standardised and comprehensive, spanning both fatal and non-fatal outcomes, and uses a mutually exclusive and collectively exhaustive list of hierarchical disease and injury causes, the study provides a powerful basis for detailed and broad insights on global health trends and emerging challenges. GBD 2019 incorporates data from 281 586 sources and provides more than 3·5 billion estimates of health outcome and health system measures of interest for global, national, and subnational policy dialogue. All GBD estimates are publicly available and adhere to the Guidelines on Accurate and Transparent Health Estimate Reporting. From this vast amount of information, five key insights that are important for health, social, and economic development strategies have been distilled. These insights are subject to the many limitations outlined in each of the component GBD capstone papers. © 2020 Elsevier Lt