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

Impact of species and antibiotic therapy of enterococcal peritonitis on 30-day mortality in critical care - An analysis of the OUTCOMEREA database

Introduction: Enterococcus species are associated with an increased morbidity in intraabdominal infections (IAI). However, their impact on mortality remains uncertain. Moreover, the influence on outcome of the appropriate or inappropriate status of initial antimicrobial therapy (IAT) is subjected to debate, except in septic shock. The aim of our study was to evaluate whether an IAT that did not cover Enterococcus spp. was associated with 30-day mortality in ICU patients presenting with IAI growing with Enterococcus spp. Material and methods: Retrospective analysis of French database OutcomeRea from 1997 to 2016. We included all patients with IAI with a peritoneal sample growing with Enterococcus. Primary endpoint was 30-day mortality. Results: Of the 1017 patients with IAI, 76 (8%) patients were included. Thirty-day mortality in patients with inadequate IAT against Enterococcus was higher (7/18 (39%) vs 10/58 (17%), p = 0.05); however, the incidence of postoperative complications was similar. Presence of Enterococcus spp. other than E. faecalis alone was associated with a significantly higher mortality, even greater when IAT was inadequate. Main risk factors for having an Enterococcus other than E. faecalis alone were as follows: SAPS score on day 0, ICU-acquired IAI, and antimicrobial therapy within 3 months prior to IAI especially with third-generation cephalosporins. Univariate analysis found a higher hazard ratio of death with an Enterococcus other than E. faecalis alone that had an inadequate IAT (HR = 4.4 [1.3-15.3], p = 0.019) versus an adequate IAT (HR = 3.1 [1.0-10.0], p = 0.053). However, after adjusting for confounders (i.e., SAPS II and septic shock at IAI diagnosis, ICU-acquired peritonitis, and adequacy of IAT for other germs), the impact of the adequacy of IAT was no longer significant in multivariate analysis. Septic shock at diagnosis and ICU-acquired IAI were prognostic factors. Conclusion: An IAT which does not cover Enterococcus is associated with an increased 30-day mortality in ICU patients presenting with an IAI growing with Enterococcus, especially when it is not an E. faecalis alone. It seems reasonable to use an IAT active against Enterococcus in severe postoperative ICU-acquired IAI, especially when a third-generation cephalosporin has been used within 3 months. © 2019 The Author(s)

Les défis des mutuelles communautaires en Afrique de l'Ouest

Quarante ans après la déclaration d'Alma-Ata en 1978, la deuxième conférence internationale sur les soins de santé primaires, qui s'est tenue en octobre 2018, a réaffirmé la place des communautés dans la gestion et la gouvernance des systèmes de santé. Dans certaines régions d'Afrique, la stratégie pour atteindre la couverture santé universelle (CSU) repose sur le développement des mutuelles communautaires de santé. Or, il existe des tensions et des écarts entre le principe de participation communautaire d'Alma-Ata, tel qu'il est actuellement interprété, et ce qui est requis pour le bon fonctionnement des mutuelles de santé communautaires. Une première tension est liée au rôle de la communauté, à la nature volontaire de l'adhésion et à l'engagement bénévole dans la gouvernance et la gestion. Nous utilisons des exemples du Rwanda, du Ghana, du Mali et du Sénégal pour montrer les défis associés à la place des communautés dans les mutuelles de santé et la nécessité de réduire le rôle des volontaires communautaires pour s'orienter plutôt sur la professionnalisation de la gestion. Les pays qui souhaitent encore compter sur les mutuelles communautaires de santé pour la CSU doivent trouver des moyens de rendre l'inscription des populations obligatoire, et renforcer la professionnalisation de la gestion des mutuelles communautaires, tout en veillant à ce que les communautés continuent d'avoir une place dans la gouvernance

Time to abandon amateurism and volunteerism : addressing tensions between the Alma-Ata principle of community participation and the effectiveness of community-based health insurance in Africa

Forty years after the 1978 Alma-Ata declaration, the second international conference on primary health care in October 2018 is expected to reaffirm the place of communities in health systems management and governance. In parts of Africa, community-based health insurance (CBHI) - with communities at the centre - is still seen as a strategy for achieving universal health coverage (UHC) - but there are tensions between the Alma-Ata principle of community participation, as currently interpreted, and CBHI. The tension relates particularly to the community's role in terms of the voluntary nature of CBHI membership and volunteer involvement of the community in governance andmanagement - this tension requires a rethink of the role of communities in CBHI. We use examples of Rwanda, Ghana, Mali and Senegal to demonstrate the challenges associated with the place of communities in CBHI, and the need to reduce the role of community volunteers in CBHI and instead focus on professionalising management. Countries that still wish to rely on CBHIs for UHC must find ways to make populations enrolment compulsory, and strengthen the professionalisation of CBHI management, while also ensuring that communities continue to have a place in CBHI governance

Hyperéosinophilie isolée précédant le diagnostic d’une fasciite à éosinophiles (maladie de Shulman)

International audienc

Atteinte osseuse axiale de la sarcoïdose

International audienc