Healthcare 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

Background National levels of personal health-care access and quality can be approximated by measuring mortality rates from causes that should not be fatal in the presence of effective medical care (ie, amenable mortality). Previous analyses of mortality amenable to health care only focused on high-income countries and faced several methodological challenges. In the present analysis, we use the highly standardised cause of death and risk factor estimates generated through the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) to improve and expand the quantification of personal health-care access and quality for 195 countries and territories from 1990 to 2015. Methods We mapped the most widely used list of causes amenable to personal health care developed by Nolte and McKee to 32 GBD causes. We accounted for variations in cause of death certification and misclassifications through the extensive data standardisation processes and redistribution algorithms developed for GBD. To isolate the effects of personal health-care access and quality, we risk-standardised cause-specific mortality rates for each geography-year by removing the joint effects of local environmental and behavioural risks, and adding back the global levels of risk exposure as estimated for GBD 2015. We employed principal component analysis to create a single, interpretable summary measure-the Healthcare Quality and Access (HAQ) Index-on a scale of 0 to 100. The HAQ Index showed strong convergence validity as compared with other health-system indicators, including health expenditure per capita (r= 0.88), an index of 11 universal health coverage interventions (r= 0.83), and human resources for health per 1000 (r= 0.77). We used free disposal hull analysis with bootstrapping to produce a frontier based on the relationship between the HAQ Index and the Socio-demographic Index (SDI), a measure of overall development consisting of income per capita, average years of education, and total fertility rates. This frontier allowed us to better quantify the maximum levels of personal health-care access and quality achieved across the development spectrum, and pinpoint geographies where gaps between observed and potential levels have narrowed or widened over time. Findings Between 1990 and 2015, nearly all countries and territories saw their HAQ Index values improve; nonetheless, the difference between the highest and lowest observed HAQ Index was larger in 2015 than in 1990, ranging from 28.6 to 94.6. Of 195 geographies, 167 had statistically significant increases in HAQ Index levels since 1990, with South Korea, Turkey, Peru, China, and the Maldives recording among the largest gains by 2015. Performance on the HAQ Index and individual causes showed distinct patterns by region and level of development, yet substantial heterogeneities emerged for several causes, including cancers in highest-SDI countries; chronic kidney disease, diabetes, diarrhoeal diseases, and lower respiratory infections among middle-SDI countries; and measles and tetanus among lowest-SDI countries. While the global HAQ Index average rose from 40.7 (95% uncertainty interval, 39.0-42.8) in 1990 to 53.7 (52.2-55.4) in 2015, far less progress occurred in narrowing the gap between observed HAQ Index values and maximum levels achieved; at the global level, the difference between the observed and frontier HAQ Index only decreased from 21.2 in 1990 to 20.1 in 2015. If every country and territory had achieved the highest observed HAQ Index by their corresponding level of SDI, the global average would have been 73.8 in 2015. Several countries, particularly in eastern and western sub-Saharan Africa, reached HAQ Index values similar to or beyond their development levels, whereas others, namely in southern sub-Saharan Africa, the Middle East, and south Asia, lagged behind what geographies of similar development attained between 1990 and 2015. Interpretation This novel extension of the GBD Study shows the untapped potential for personal health-care access and quality improvement across the development spectrum. Amid substantive advances in personal health care at the national level, heterogeneous patterns for individual causes in given countries or territories suggest that few places have consistently achieved optimal health-care access and quality across health-system functions and therapeutic areas. This is especially evident in middle-SDI countries, many of which have recently undergone or are currently experiencing epidemiological transitions. The HAQ Index, if paired with other measures of health-systemcharacteristics such as intervention coverage, could provide a robust avenue for tracking progress on universal health coverage and identifying local priorities for strengthening personal health-care quality and access throughout the world. Copyright (C) The Author(s). Published by Elsevier Ltd.Peer reviewe

Risky Business - large-scale land investments and possibilities of safeguarding the rural poor in Ethiopia

In the Global South lifting people out of poverty and ensuring food security is of crucial significance. While many hopes are drawn towards the possibilities of economic growth, rural development and production efficiencies gained by attracting investors and capital to the agricultural sector, such activities also threaten to expose vulnerable rural communities. This study investigates what risks are faced by rural communities in presence of large-scale land investors for biofuel production. Through studying three large-scale land investments in Ethiopia, their impacts on the rural communities and the efficiency in the safeguarding measures already put in place, this study aims to understand what measures can be carried out in the future to protect these rural poor. A qualitative interview-based study is conducted at these three sites and the results are analyzed in the light of international guidelines for responsible investments in the agricultural sector, the Ethiopian national policy for agriculture and rural development and theories on pro-poor growth. The result of the study shows that the risks are many and severely threatens the livelihoods of the rural poor as their economical margins are very limited. Providing information, complement mal-functioning markets with unions or cooperatives and pushing towards the strengthening of political representation of the members of these communities are for the specific cases studied possible measures in mitigating some of these risks. The study also argues that the often promoted ‘win-win’ investment strategy of out-grower schemes can substantially increase the farmers’ vulnerability and that the notion of idle or available land, without investigation on the ground, can be misleading

Ain’t our business? A study of transnational climate change impacts on Swedish consumption through the lens of Brazilian soy

Over the past decades the world has become increasingly interconnected, and global commodity trade has increased substantially in scope and complexity. Simultaneously, we are rapidly moving towards a future with an increased risk of severe disruption caused by the effects of climate change globally. As trade flows can connect distant regions thousands of miles apart, they can also transmit risks of climate change via impacts on supply chains. This study examines these risk flows through a case study, focusing on exposure to climate change risks to the Swedish consumption of Brazilian soy. Taking in to account both the exposure of climate change to agricultural production in Brazil, and the potential climate vulnerability of the transport network that is used in the agricultural supply, this study brings together data and methods from eight different sources to assess climate risks to production and transport in a novel integrated climate risk assessment. The ability to link consumption data, production data and transport network information together at a municipality resolution constitutes a major innovation and step forward in climate-related supply chain risk assessment. The study find that future risks posed to Swedish sourcing of Brazilian soy are relatively low. Considering dynamic effects of the future market does however suggest that securing future supplies of soy can still be a challenging task for Sweden

Alcohol consumption habits and associations with anxiety or depressive symptoms postpartum in women with high socioeconomic status in Sweden.

Postpar tum depression and anxiety are common among new mothers. It is well-established that in the general population alcohol use is associated with depression and anxiety. Linking alcohol consumption to symptoms of postpartum depression (PPDS) or postpartum anxiety (PPAS) is presently less established. This study aims to determine if alcohol consumption pre-pregnancy, 6 weeks postpartum, 6 months postpartum, or changes in alcohol consumption are associated with PPDS or PPAS. Longitudinal data on 3849 women from a Swedish perinatal cohort were analyzed using logistic regression analyses for associations between alcohol consumption and symptoms of anxiety or depression, as assessed with the Edinburgh Postnatal Depression Scale. There was no association between pre-pregnancy drinking habits and PPDS (p = 0.588, n = 2479) or PPAS (p = 0.942; n = 2449) at 6 weeks postpartum. Similarly, no associations were observed between concurrent drinking habits at 6 weeks postpartum and PPAS (p = 0.070, n = 3626), 6 months postpartum and PPDS (0.647, n = 3461) or PPAS (p = 0.700, n = 3431). However, there was an association between drinking habits at 6 weeks postpartum and concurrent PPDS (p = 0.047, n = 3659). In conclusion, robust associations were not found between postpartum alcohol consumption and mood symptoms. This lack of association between poor mental health and risk behaviors in new mothers could be interpreted as a result of long-term policy work and high participation in Swedish maternity care. Future studies need to address these research questions in more diverse socio-cultural contexts

Nordic Perspectives on Transboundary Climate Risk : Current knowledge and pathways for action

Climate impacts hit us directly as e.g. floods and forest fires, but also cascade over borders. How can we address these transboundary climate risks (TCRs)? To answer this, the Nordic Council of Ministers commissioned a study. As open economies, the Nordics can be exposed to TCRs. Some key trade partners have medium (e.g. China) or even high (e.g. India) risk. The study dove deeper into six food commodities. For example, climate change affects sources of maize negatively, with risks outweighing opportunities by 28:1. This can mean higher prices or disturbances in supplies. The Nordics are better prepared than most others, but not well enough. There are also important differences among them. The report makes recommendations on how Nordics can better address TCRs together. These include a joint research programme, raising awareness and engaging with the private sector

POLICY BRIEF: Nordic Perspectives on Transboundary Climate Risk

Climate impacts hit us directly as e.g. floods and forest fires, but also cascade over borders. How can we address these transboundary climate risks (TCRs)? To answer this, the Nordic Council of Ministers commissioned a study. As open economies, the Nordics can be exposed to TCRs. Some key trade partners have medium (e.g. China) or even high (e.g. India) risk. The study dove deeper into six food commodities. For example, climate change affects sources of maize negatively, with risks outweighing opportunities by 28:1. This can mean higher prices or disturbances in supplies. The Nordics are better prepared than most others, but not well enough. There are also important differences among them. The report makes recommendations on how Nordics can better address TCRs together. These include a joint research programme, raising awareness and engaging with the private sector

Think global-act local: the challenge of producing actionable knowledge on transboundary climate risks at the sub-national level of governance.

A growing number of countries are putting transboundary climate risks on their national adaptation policy agenda. The designation of subnational governments as key actors in climate change adaptation policy appears to be appropriate when the risks associated with climate change are defined as “local.” In this study we have investigated whether local authorities can plausibly play an equally central role when it comes to transboundary climate risks. Three cases have been studied: Paris in France and the topic of migration and integration, Klepp in Norway and the topic of agriculture and livestock production, and the river harbors in the Upper Rhine region of France and the topic of freight transportation and river regulation. Even if the sub-national actors involved in the three cases showed strong interest in analyzing and addressing transboundary climate risks, it remains an open question whether such authorities can and should play an equally central role in addressing transboundary climate risks as they do in the case of local climate risks. On the other hand, assigning responsibility for managing transboundary climate risks exclusively to national authorities may increase the risk of conflicts between measures to reduce local climate risks (frequently developed and implemented by sub-national authorities) and transboundary climate risks. The authors of this paper therefore advocate a strong partnership between the different levels of governance, and between public and private-sector stakeholders, in adaptation to transboundary climate risk. It is therefore crucial that national governments explicitly account for transboundary climate risks in their national adaptation agendas and, as part of their process in determining “ownership” of such risks, decide on the role sub-national authorities should play. This choice will also affect the role of local authorities in managing local climate risks due to the interlinkages between them

Towards improved adaptation action in Europe: Policy recommendations from the UNCHAIN project

Policymakers can make adaptation "smarter" by using the Impact Chain approach to analyse both conventional local climate risks and lesser well-known transboundary climate risks. • Policymakers should embrace uncertainties by applying a reflect-then-act rather than the predict-then-act approach; by including socioeconomic scenarios for a range of possible developments, from likely to unanticipated; and by ensuring transparency in communications. Below we summarize our policy-relevant insights and recommendations for the European Commission and EU member states