Hunger for an Education: A Research Essay on the Case of South Sudan and the Voices of Its People

The Republic of South Sudan is one of the newest of all African countries having become an independent state on July 9, 2011. After years of prolonged war, beginning in the mid-1950s, among different political, tribal, and military factions, and with the Sudan, the South Sudan is now a full-fledged country. The country continues to deal with the legacy of colonialism, genocide, and oppression, and is involved in a civil war. As a result of this legacy, the country faces many challenges especially in the development of a social, political, and economic infrastructure which can develop into a democratic state and implement a viable public school system that can feed universities and technical schools. At this time, approximately 42% of the country’s population is below 14 years of age, and the “school life expectancy” index is only four years for males and even less for females. The educational system in the South Sudan can be described as disorganized, fragmented, and a “patchwork” of schools that are seasonal and temporary, and with a disjointed mission. Also, each of the ten states that comprise the country seems to function independently although there is a master plan for the overall country. Yet, common to all of these states is the lack of school buildings, teachers and support staff, and an organized and proven curriculum for all of the nation’s youth. For this research essay, five South Sudanese persons, with a role in education were interviewed to identify the most critical problems in the current educational system. While the results of interviews are limited in representative scope, the results are strongly reflective of the condition of the educational system in the South Sudan. Various recommendations are suggested by the authors. दक्षिण सूडान गणराज्य 9 जुलाई 2011 को एक स्वतंत्र राज्य बनने के सभी अफ्रीकी देशों के नवीनतम में से एक है . लंबे समय तक युद्ध के वर्षों के बाद , विभिन्न राजनीतिक, आदिवासी , और सैन्य गुटों के बीच , 1950 के मध्य में शुरू , और सूडान के साथ , दक्षिण सूडान अब एक पूर्ण विकसित देश है . देश उपनिवेशवाद , नरसंहार , और उत्पीड़न की विरासत के साथ सौदा करने के लिए जारी है , और एक नागरिक युद्ध में शामिल है . इस विरासत का एक परिणाम के रूप में , देश विशेष रूप से एक लोकतांत्रिक राज्य में विकसित और विश्वविद्यालयों और तकनीकी स्कूलों फ़ीड कर सकते हैं कि एक व्यवहार्य पब्लिक स्कूल प्रणाली को लागू कर सकते हैं जो एक सामाजिक, राजनीतिक , और आर्थिक बुनियादी ढांचे के विकास में कई चुनौतियां हैं. इस समय, देश की आबादी का लगभग 42 % की उम्र 14 साल से कम है , और स्कूल जीवन प्रत्याशा \u22 सूचकांक पुरुषों के लिए केवल चार साल है और भी कम महिलाओं के लिए . दक्षिण सूडान में शिक्षा प्रणाली , बेतरतीब खंडित , और मौसमी और अस्थायी हैं कि स्कूलों की एक चिथड़े , और एक असंबद्ध मिशन के साथ के रूप में वर्णित किया जा सकता है . इसके अलावा , देश शामिल है कि दस राज्यों में से प्रत्येक में समग्र देश के लिए एक मास्टर प्लान है, हालांकि वहां स्वतंत्र रूप से कार्य करने लगता है. फिर भी, इन राज्यों में से सभी के लिए आम स्कूल भवनों , शिक्षकों और सहयोगी स्टाफ की कमी है, और देश के युवाओं के सभी के लिए एक संगठित और सिद्ध पाठ्यक्रम है . इस शोध निबंध के लिए , शिक्षा के क्षेत्र में एक भूमिका के साथ पांच सूडानी दक्षिण व्यक्तियों , वर्तमान शिक्षा प्रणाली में सबसे महत्वपूर्ण समस्याओं की पहचान करने के लिए बातचीत की गई. साक्षात्कार के परिणामों प्रतिनिधि दायरे में सीमित कर रहे हैं, परिणाम दक्षिण सूडान में शिक्षा व्यवस्था की हालत का दृढ़ता से विचार कर रहे हैं . विभिन्न सिफारिशों लेखकों ने सुझाव दिया है . 南苏丹共和国是非洲最新成立的国家之一，它于2011年7月9日宣布独立。经过了开始于20世纪中叶的长期战争，经过与苏丹不同的政治、族群以及军事宗派间的斗争后，现在的南苏丹是一个羽翼丰满的国家。国家持续与殖民主义、种族屠杀和压迫做斗争，并卷入内战。结果，国家面临着很多挑战，特别是社会、政治以及经济基础设施的发展可以使南苏丹发展为一个民主和独立发展大学、技术学校的公立学校系统的国家。如今，大约42%的国家人口年龄小于14岁，男性“人均预期受教育年限”指数只有四年，女性则更少。南苏丹的教育系统可以用混乱、脆弱以及“缝补”的临时性学校来形容。尽管整个国家有着宏大的计划，但似乎组成这个国家的十个州是独立运作的。这十个州的共同点是缺乏学校建筑物、教师和员工，以及全国年轻一代所需要的课程设置。本研究中采访了五个在教育中担任职务的南苏丹人，他们总结出目前南苏丹教育系统中最关键的问题。尽管访谈的结果在代表性上具有局限性，但结果仍然强烈地反应了南苏丹教育体系的现状。作者相应地提出了多种建议。 Die Republik Süd-Sudan ist einer der neuesten aller afrikanischen Länder, die am 9. Juli 2011 ein unabhängiger Staat geworden ist. Nach Jahren anhaltenden Kriegs, beginnend in der Mitte der 1950er Jahre zwischen verschiedenen politischen, Stammes- und militärischen Gruppierungen und den Sudan ist der Süd-Sudan jetzt ein vollwertiges Land. Das Land kämpft weiterhin mit dem Erbe des Kolonialismus, Völkermord und Unterdrückung und ist in einem Bürgerkrieg verfallen. Infolge dieses Erbe steht das Land vor vielen Herausforderungen vor allem bei der Entwicklung einer sozialen, politischen und wirtschaftlichen Infrastruktur, die es zu einem demokratischen Staat entwickeln und ein tragfähiges öffentliches Schulsystems implementieren kann, das Universitäten und technischen Schulen zu unterstützen in der Lage ist. Gegenwärtig sind etwa 42 % der Bevölkerung des Landes unter 14 Jahren alt und der Schulbesucherwartungsindex („school life expectancy“) beträgt nur vier Jahre für Männer und noch weniger für Frauen. Das Bildungssystem in den Süd-Sudan kann man als desorganisiert, fragmentiert, und ein „Flickenteppich“ von Schulen, die nur saisonal und befristet operieren, und mit einem separaten Auftrag. Auch jeder der zehn Staaten, die das Land bilden, scheint unabhängig voneinander zu funktionieren, obwohl es ein Masterplan für das gesamte Land gibt. Doch alle diesen Staaten gemeinsam ist der Mangel an Schulgebäuden, Lehrpersonen und Unterstützungsmitarbeiter_innen sowie ein organisiertes und bewährtes Lehrplan für die Jugend des Landes. Für das vorliegende Forschungsessay wurden fünf süd-sudanesische Personen mit einer Rolle im Bildungsbereich befragt, um die wichtigsten Probleme im aktuellen Bildungssystem zu identifizieren. Während die Ergebnisse der Interviews in Bezug auf ihre Repräsentativität begrenzt ist, sind die Ergebnisse stark kennzeichnend für den Zustand des Bildungssystems in Süd-Sudan. Verschiedene Empfehlungen werden von den Autor_innen vorgeschlagen. 9 Temmuz 2011\u27 de bağımsızlığını ilan eden Güney Sudan Cumhuriyeti Afrika\u27nın en yeni ülkelerinden birisidir. 1950\u27lilerin ortasında farklı siyasi, kabile, ve askeri gruplar arasında ve Sudan\u27 la başlayan, uzun yıllar süren savaştan sonra Güney Sudan bugün bağımsız bir ülkedir. Güney Sudan sömürgeciliğin mirası, soykırım ve baskıyla uğraşmaya devam ederken aynı zamanda iç savaşla uğraşmaktadır. Almış olduğu mirasın sonucu olarak, Güney Sudan özellikle kendisini demokratik devlet haline getirecek ve üniversiteleri ve teknik okulları destekleyecek uygulanabilir kamu eğitim sistemini sağlayacak olan sosyal, politik, ve ekonomik altyapının geliştirilmesi konusunda zorluk çekmektedir. Şu anda ülke nüfusunun yaklaşık olarak yüzde kırk iki\u27si on dört yaş altındadır ve okul hayatı beklenti endeksi erkekler için sadece dört yıl, kadınlar içinse dört yıldan daha azdır. Güney Sudan eğitim sistemi düzensiz, dönemlik, ve daimi olmayan okulların tutarsız bir misyonla parçalandığı eğitim sistemi olarak tanımlanabilir. Ayrıca her ne kadar ülke genelinde ana bir plan olsa\u27 da, ülkeyi oluşturan on eyaletin her biri bağımsız olarak hareket ediyor görünmektedir. Oysa ki, eyaletlerin tamamında ortak olan nokta okul binalarının, öğretmenlerin ve destek personelin, ve ülke gençliğinin tamamı için hazırlanmış ve onaylanmış müfredat programının eksikliğidir. Bu arastirmada mevcut eğitim sistemindeki en ciddi problemleri tanımlamak amacıyla eğitim sisteminde rol alan beş Sudanlı kişiyle mülakat yapılmıştır. Her ne kadar mülakat sonuçları kapsam açısından sınırlı olsa\u27 da, sonuçlar Güney Sudan eğitim sisteminin mevcut durumunu önemli ölçüde yansıtmaktadır. Bu bağlamda yazarlar tarafından çeşitli önerilerde bulunulmuştur. جمهورية جنوب السودان واحدة من أحدث الدول الإفريقية بعد أن أصبحت دولة مستقلة في 9 يوليه عام 2011. فبعد سنوات من الحرب الطويلة التي بدأت في منتصف خمسينات القرن العشرين بين فصائل سياسية وقبلية وعسكرية مختلفة، وكذلك مع السودان، أصبح جنوب السودان الآن دولة مستقلة كاملة السيادة، وتستمر الدولة في التعامل مع ما خلَّفَه الاستعمار والإبادة الجماعية والقهر، كما أنها متورطة في حرب أهلية. نتيجة لذلك الإرث، تواجه الدولة العديد من التحديات، بالأخص فيما يتعلق بإنشاء بنية تحتية اجتماعية وسياسية واقتصادية تمكنها من التطور لتصبح دولة ديمقراطية تطبق نظامًا تعليميًا حكوميًا صالحًا يمكنه أن يمد الجامعات والمدارس الفنية. وفي الوقت الحالي، حوالي2 4% من سكان الدولة دون سن الأربعة عشر عاما ومؤشر عمر القبول بالمدارس هو أربعة أعوام فقط للأولاد، بل وأقل من ذلك للفتيات. ويمكن وصف النظام التعليمي في جنوب السودان بأنه غير منظم ومفتت وأنه عمل غير مكتمل لمدارس تعمل بصفة موسمية ومؤقتة وبهدف غير مترابط، كما يبدو أيضا أن كل ولاية من الولايات العشرة التي تتكون منها الدولة تعمل بمفردها بالرغم من وجود خطة شاملة للبلد بأكملها. ويبقى الشيء المشترك بين جميع هذه الولايات هو قلة المباني التعليمية والمدرسين والموظفين المساعدين ومنهج دراسي منظم ثبتت كفاءته لجميع شباب هذه البلد. ومن أجل عمل هذا المقال البحثي، جرت مقابلة خمسة أشخاص من جنوب السودان لهم دور في العملية التعليمية لتحديد أكثر المشكلات خطورة في نظام التعليم الحالي. وبينما كانت نتائج أفراد المقابلات محدودة فيما يتعلق بالنطاق الذي يمثلونه، عكست النتائج بقوة حالة النظام التعليمي في جنوب السودان، ويقترح المؤلفون العديد من التوصيات

Multielemental analysis of Antarctic soils using calibration free laser-induced breakdown spectroscopy

Laser-induced breakdown spectroscopy (LIBS) is a quick technique that allows the analysis of all types of samples without destroying them and with much reduced sample treatment. One of its many applications is the study of geological samples such as soils. Because of the complexity of the matrix, it is very difficult to find or manufacture standards for these types of samples. Therefore, a good alternative is to make use of a methodology, called Calibration Free (CF), where instead of using standards, the physical parameters of the plasma created by the interaction of the laser with the sample are studied and related to the elements and species that compose it. This methodology is followed to perform a multielemental quantitative analysis of soil samples from Antarctica. Two studies were made, differing in the optimization of the instrumental parameters in order to obtain the best possible spectra in the chosen spectral lines. In both cases, the signal to noise ratio (SNR) was used to evaluate the quality of the spectra, but in the second study a full factorial design 23 with center and axial points was developed to get better results. The choice of spectral lines was based on a series of criteria, being stricter in the second study. The samples were mainly composed of the following oxides: SiO2, Al2O3, Fe2O3, CaO, MgO, Na2O, TiO and K2O. In the second study, it was also possible to determine the species present in lower concentrations: Mn, Cr, V, Sr, Zr, BA and Li. The results were compared with those provided by ICP-OES analysis, obtaining close values for most oxides, especially in the second study. For minority elements, the CF-LIBS and the ICP-OES results were within the same order of magnitude in all cases except the Cr case. These results show that CF-LIBS can be very useful in the characterization of complex samples from remote regions, such as Antarctic soils

Conscious mobility for urban spaces: case studies review and indicator framework design

A lack of data collection on conscious mobility behaviors has been identified in current sustainable and smart mobility planning, development and implementation strategies. This leads to technocentric solutions that do not place people and their behavior at the center of new mobility solutions in urban centers around the globe. This paper introduces the concept of conscious mobility to link techno-economic analyses with user awareness on the impact of their travel decisions on other people, local urban infrastructure and the environment through systematic big data collection. A preliminary conscious mobility indicator framework is presented to leverage behavioral considerations to enhance urban-community mobility systems. Key factors for conscious mobility analysis have been derived from five case studies. The sample offers regional diversity (i.e., local, regional and the global urban contexts), as well as different goals in the transformation of conventional urban transport systems, from improving public transport efficiency and equipment electrification to mitigate pollution and climate risks, to focusing on equity, access and people safety. The case studies selected provide useful metrics on the adoption of cleaner, smarter, safer and more autonomous mobility technologies, along with novel people-centric program designs to build an initial set of conscious mobility indicators frameworks. The parameters were applied to the city of Monterrey, Nuevo Leon in Mexico focusing on the needs of the communities that work, study and live around the local urban campus of the Tecnologico de Monterrey’s Distrito Tec. This case study, served as an example of how conscious mobility indicators could be applied and customized to a community and region of interest. This paper introduces the first application of the conscious mobility framework for urban communities’ mobility system analysis. This more holistic assessment approach includes dimensions such as society and culture, infrastructure and urban spaces, technology, government, normativity, economy and politics, and the environment. The expectation is that the conscious mobility framework of analysis will become a useful tool for smarter and sustainable urban and mobility problem solving and decision making to enhance the quality of life all living in urban communities

Dietary factors associated with metabolic syndrome in Brazilian adults

<p>Abstract</p> <p>Background</p> <p>Metabolic Syndrome (MS) is defined as the association of numerous factors that increase cardiovascular risk and diet is one of the main factors related to increase the MS in the population. This study aimed to evaluate the association of diet on the presence of MS in an adult population sample.</p> <p>Methodology</p> <p>305 adults were clinically screened to participate in a lifestyle modification program. Anthropometric assessments included waist circumference (WC), body fat and calculated BMI (kg/m²) and muscle-mass index (MMI kg/m²). Dietary intake was estimated by 24 h dietary recall. Fasting blood was used for biochemical analysis. MS was diagnosed using NCEP-ATPIII (2001) criteria with adaptation for glucose (≥ 100 mg/dL). Logistic regression (Odds ratio) was performed in order to determine the odds ratio for developing MS according to dietary intake.</p> <p>Results</p> <p>An adequate intake of fruits, OR = 0.52 (CI:0.28-0.98), and an intake of more than 8 different items in the diet (variety), OR = 0.31 (CI:0.12-0.79) showed to be a protective factor against a diagnosis of MS. Saturated fat intake greater than 10% of total caloric value represented a risk for MS diagnosis, OR = 2.0 (1.04-3.84).</p> <p>Conclusion</p> <p>Regarding the dietary aspect, a risk factor for MS was higher intake of saturated fat, and protective factors were high diet variety and adequate fruit intake.</p

The Biodiversity of the Mediterranean Sea: Estimates, Patterns, and Threats

The Mediterranean Sea is a marine biodiversity hot spot. Here we combined an extensive literature analysis with expert opinions to update publicly available estimates of major taxa in this marine ecosystem and to revise and update several species lists. We also assessed overall spatial and temporal patterns of species diversity and identified major changes and threats. Our results listed approximately 17,000 marine species occurring in the Mediterranean Sea. However, our estimates of marine diversity are still incomplete as yet—undescribed species will be added in the future. Diversity for microbes is substantially underestimated, and the deep-sea areas and portions of the southern and eastern region are still poorly known. In addition, the invasion of alien species is a crucial factor that will continue to change the biodiversity of the Mediterranean, mainly in its eastern basin that can spread rapidly northwards and westwards due to the warming of the Mediterranean Sea. Spatial patterns showed a general decrease in biodiversity from northwestern to southeastern regions following a gradient of production, with some exceptions and caution due to gaps in our knowledge of the biota along the southern and eastern rims. Biodiversity was also generally higher in coastal areas and continental shelves, and decreases with depth. Temporal trends indicated that overexploitation and habitat loss have been the main human drivers of historical changes in biodiversity. At present, habitat loss and degradation, followed by fishing impacts, pollution, climate change, eutrophication, and the establishment of alien species are the most important threats and affect the greatest number of taxonomic groups. All these impacts are expected to grow in importance in the future, especially climate change and habitat degradation. The spatial identification of hot spots highlighted the ecological importance of most of the western Mediterranean shelves (and in particular, the Strait of Gibraltar and the adjacent Alboran Sea), western African coast, the Adriatic, and the Aegean Sea, which show high concentrations of endangered, threatened, or vulnerable species. The Levantine Basin, severely impacted by the invasion of species, is endangered as well

Measuring 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

Background: A key component of achieving universal health coverage is ensuring that all populations have access to quality health care. Examining where gains have occurred or progress has faltered across and within countries is crucial to guiding decisions and strategies for future improvement. We used the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) to assess personal health-care access and quality with the Healthcare Access and Quality (HAQ) Index for 195 countries and territories, as well as subnational locations in seven countries, from 1990 to 2016. Methods Drawing from established methods and updated estimates from GBD 2016, we used 32 causes from which death should not occur in the presence of effective care to approximate personal health-care access and quality by location and over time. To better isolate potential effects of personal health-care access and quality from underlying risk factor patterns, we risk-standardised cause-specific deaths due to non-cancers by location-year, replacing the local joint exposure of environmental and behavioural risks with the global level of exposure. Supported by the expansion of cancer registry data in GBD 2016, we used mortality-to-incidence ratios for cancers instead of risk-standardised death rates to provide a stronger signal of the effects of personal health care and access on cancer survival. We transformed each cause to a scale of 0-100, with 0 as the first percentile (worst) observed between 1990 and 2016, and 100 as the 99th percentile (best); we set these thresholds at the country level, and then applied them to subnational locations. We applied a principal components analysis to construct the HAQ Index using all scaled cause values, providing an overall score of 0-100 of personal health-care access and quality by location over time. We then compared HAQ Index levels and trends by quintiles on the Socio-demographic Index (SDI), a summary measure of overall development. As derived from the broader GBD study and other data sources, we examined relationships between national HAQ Index scores and potential correlates of performance, such as total health spending per capita. Findings In 2016, HAQ Index performance spanned from a high of 97\ub71 (95% UI 95\ub78-98\ub71) in Iceland, followed by 96\ub76 (94\ub79-97\ub79) in Norway and 96\ub71 (94\ub75-97\ub73) in the Netherlands, to values as low as 18\ub76 (13\ub71-24\ub74) in the Central African Republic, 19\ub70 (14\ub73-23\ub77) in Somalia, and 23\ub74 (20\ub72-26\ub78) in Guinea-Bissau. The pace of progress achieved between 1990 and 2016 varied, with markedly faster improvements occurring between 2000 and 2016 for many countries in sub-Saharan Africa and southeast Asia, whereas several countries in Latin America and elsewhere saw progress stagnate after experiencing considerable advances in the HAQ Index between 1990 and 2000. Striking subnational disparities emerged in personal health-care access and quality, with China and India having particularly large gaps between locations with the highest and lowest scores in 2016. In China, performance ranged from 91\ub75 (89\ub71-93\ub76) in Beijing to 48\ub70 (43\ub74-53\ub72) in Tibet (a 43\ub75-point difference), while India saw a 30\ub78-point disparity, from 64\ub78 (59\ub76-68\ub78) in Goa to 34\ub70 (30\ub73-38\ub71) in Assam. Japan recorded the smallest range in subnational HAQ performance in 2016 (a 4\ub78-point difference), whereas differences between subnational locations with the highest and lowest HAQ Index values were more than two times as high for the USA and three times as high for England. State-level gaps in the HAQ Index in Mexico somewhat narrowed from 1990 to 2016 (from a 20\ub79-point to 17\ub70-point difference), whereas in Brazil, disparities slightly increased across states during this time (a 17\ub72-point to 20\ub74-point difference). Performance on the HAQ Index showed strong linkages to overall development, with high and high-middle SDI countries generally having higher scores and faster gains for non-communicable diseases. Nonetheless, countries across the development spectrum saw substantial gains in some key health service areas from 2000 to 2016, most notably vaccine-preventable diseases. Overall, national performance on the HAQ Index was positively associated with higher levels of total health spending per capita, as well as health systems inputs, but these relationships were quite heterogeneous, particularly among low-to-middle SDI countries. Interpretation GBD 2016 provides a more detailed understanding of past success and current challenges in improving personal health-care access and quality worldwide. Despite substantial gains since 2000, many low-SDI and middle- SDI countries face considerable challenges unless heightened policy action and investments focus on advancing access to and quality of health care across key health services, especially non-communicable diseases. Stagnating or minimal improvements experienced by several low-middle to high-middle SDI countries could reflect the complexities of re-orienting both primary and secondary health-care services beyond the more limited foci of the Millennium Development Goals. Alongside initiatives to strengthen public health programmes, the pursuit of universal health coverage hinges upon improving both access and quality worldwide, and thus requires adopting a more comprehensive view-and subsequent provision-of quality health care for all populations

Canagliflozin and renal outcomes in type 2 diabetes and nephropathy

BACKGROUND Type 2 diabetes mellitus is the leading cause of kidney failure worldwide, but few effective long-term treatments are available. In cardiovascular trials of inhibitors of sodium–glucose cotransporter 2 (SGLT2), exploratory results have suggested that such drugs may improve renal outcomes in patients with type 2 diabetes. METHODS In this double-blind, randomized trial, we assigned patients with type 2 diabetes and albuminuric chronic kidney disease to receive canagliflozin, an oral SGLT2 inhibitor, at a dose of 100 mg daily or placebo. All the patients had an estimated glomerular filtration rate (GFR) of 30 to &lt;90 ml per minute per 1.73 m2 of body-surface area and albuminuria (ratio of albumin [mg] to creatinine [g], &gt;300 to 5000) and were treated with renin–angiotensin system blockade. The primary outcome was a composite of end-stage kidney disease (dialysis, transplantation, or a sustained estimated GFR of &lt;15 ml per minute per 1.73 m2), a doubling of the serum creatinine level, or death from renal or cardiovascular causes. Prespecified secondary outcomes were tested hierarchically. RESULTS The trial was stopped early after a planned interim analysis on the recommendation of the data and safety monitoring committee. At that time, 4401 patients had undergone randomization, with a median follow-up of 2.62 years. The relative risk of the primary outcome was 30% lower in the canagliflozin group than in the placebo group, with event rates of 43.2 and 61.2 per 1000 patient-years, respectively (hazard ratio, 0.70; 95% confidence interval [CI], 0.59 to 0.82; P=0.00001). The relative risk of the renal-specific composite of end-stage kidney disease, a doubling of the creatinine level, or death from renal causes was lower by 34% (hazard ratio, 0.66; 95% CI, 0.53 to 0.81; P&lt;0.001), and the relative risk of end-stage kidney disease was lower by 32% (hazard ratio, 0.68; 95% CI, 0.54 to 0.86; P=0.002). The canagliflozin group also had a lower risk of cardiovascular death, myocardial infarction, or stroke (hazard ratio, 0.80; 95% CI, 0.67 to 0.95; P=0.01) and hospitalization for heart failure (hazard ratio, 0.61; 95% CI, 0.47 to 0.80; P&lt;0.001). There were no significant differences in rates of amputation or fracture. CONCLUSIONS In patients with type 2 diabetes and kidney disease, the risk of kidney failure and cardiovascular events was lower in the canagliflozin group than in the placebo group at a median follow-up of 2.62 years

Measuring 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

Copyright © 2018 The Author(s). Published by Elsevier Ltd. Background A key component of achieving universal health coverage is ensuring that all populations have access to quality health care. Examining where gains have occurred or progress has faltered across and within countries is crucial to guiding decisions and strategies for future improvement. We used the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) to assess personal health-care access and quality with the Healthcare Access and Quality (HAQ) Index for 195 countries and territories, as well as subnational locations in seven countries, from 1990 to 2016. Methods Drawing from established methods and updated estimates from GBD 2016, we used 32 causes from which death should not occur in the presence of effective care to approximate personal health-care access and quality by location and over time. To better isolate potential effects of personal health-care access and quality from underlying risk factor patterns, we risk-standardised cause-specific deaths due to non-cancers by location-year, replacing the local joint exposure of environmental and behavioural risks with the global level of exposure. Supported by the expansion of cancer registry data in GBD 2016, we used mortality-to-incidence ratios for cancers instead of risk-standardised death rates to provide a stronger signal of the effects of personal health care and access on cancer survival. We transformed each cause to a scale of 0-100, with 0 as the first percentile (worst) observed between 1990 and 2016, and 100 as the 99th percentile (best); we set these thresholds at the country level, and then applied them to subnational locations. We applied a principal components analysis to construct the HAQ Index using all scaled cause values, providing an overall score of 0-100 of personal health-care access and quality by location over time. We then compared HAQ Index levels and trends by quintiles on the Socio-demographic Index (SDI), a summary measure of overall development. As derived from the broader GBD study and other data sources, we examined relationships between national HAQ Index scores and potential correlates of performance, such as total health spending per capita. Findings In 2016, HAQ Index performance spanned from a high of 97·1 (95% UI 95·8-98·1) in Iceland, followed by 96·6 (94·9-97·9) in Norway and 96·1 (94·5-97·3) in the Netherlands, to values as low as 18·6 (13·1-24·4) in the Central African Republic, 19·0 (14·3-23·7) in Somalia, and 23·4 (20·2-26·8) in Guinea-Bissau. The pace of progress achieved between 1990 and 2016 varied, with markedly faster improvements occurring between 2000 and 2016 for many countries in sub-Saharan Africa and southeast Asia, whereas several countries in Latin America and elsewhere saw progress stagnate after experiencing considerable advances in the HAQ Index between 1990 and 2000. Striking subnational disparities emerged in personal health-care access and quality, with China and India having particularly large gaps between locations with the highest and lowest scores in 2016. In China, performance ranged from 91·5 (89·1-93·6) in Beijing to 48·0 (43·4-53·2) in Tibet (a 43·5-point difference), while India saw a 30·8-point disparity, from 64·8 (59·6-68·8) in Goa to 34·0 (30·3-38·1) in Assam. Japan recorded the smallest range in subnational HAQ performance in 2016 (a 4·8-point difference), whereas differences between subnational locations with the highest and lowest HAQ Index values were more than two times as high for the USA and three times as high for England. State-level gaps in the HAQ Index in Mexico somewhat narrowed from 1990 to 2016 (from a 20·9-point to 17·0-point difference), whereas in Brazil, disparities slightly increased across states during this time (a 17·2-point to 20·4-point difference). Performance on the HAQ Index showed strong linkages to overall development, with high and high-middle SDI countries generally having higher scores and faster gains for non-communicable diseases. Nonetheless, countries across the development spectrum saw substantial gains in some key health service areas from 2000 to 2016, most notably vaccine-preventable diseases. Overall, national performance on the HAQ Index was positively associated with higher levels of total health spending per capita, as well as health systems inputs, but these relationships were quite heterogeneous, particularly among low-to-middle SDI countries. Interpretation GBD 2016 provides a more detailed understanding of past success and current challenges in improving personal health-care access and quality worldwide. Despite substantial gains since 2000, many low-SDI and middle- SDI countries face considerable challenges unless heightened policy action and investments focus on advancing access to and quality of health care across key health services, especially non-communicable diseases. Stagnating or minimal improvements experienced by several low-middle to high-middle SDI countries could reflect the complexities of re-orienting both primary and secondary health-care services beyond the more limited foci of the Millennium Development Goals. Alongside initiatives to strengthen public health programmes, the pursuit of universal health coverage hinges upon improving both access and quality worldwide, and thus requires adopting a more comprehensive view - and subsequent provision - of quality health care for all populations