Assessing performance of the Healthcare Access and Quality Index, overall and by select age groups, for 204 countries and territories, 1990–2019: a systematic analysis from the Global Burden of Disease Study 2019

GBD 2019 Healthcare Access and Quality Collaborators

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Health-care needs change throughout the life course. It is thus crucial to assess whether health systems provide access to quality health care for all ages. Drawing from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019 (GBD 2019), we measured the Healthcare Access and Quality (HAQ) Index overall and for select age groups in 204 locations from 1990 to 2019.

We distinguished the overall HAQ Index (ages 0–74 years) from scores for select age groups: the young (ages 0–14 years), working (ages 15–64 years), and post-working (ages 65–74 years) groups. For GBD 2019, HAQ Index construction methods were updated to use the arithmetic mean of scaled mortality-to-incidence ratios (MIRs) and risk-standardised death rates (RSDRs) for 32 causes of death that should not occur in the presence of timely, quality health care. Across locations and years, MIRs and RSDRs were scaled from 0 (worst) to 100 (best) separately, putting the HAQ Index on a different relative scale for each age group. We estimated absolute convergence for each group on the basis of whether the HAQ Index grew faster in absolute terms between 1990 and 2019 in countries with lower 1990 HAQ Index scores than countries with higher 1990 HAQ Index scores and by Socio-demographic Index (SDI) quintile. SDI is a summary metric of overall development.

Between 1990 and 2019, the HAQ Index increased overall (by 19·6 points, 95% uncertainty interval 17·9–21·3), as well as among the young (22·5, 19·9–24·7), working (17·2, 15·2–19·1), and post-working (15·1, 13·2–17·0) age groups. Large differences in HAQ Index scores were present across SDI levels in 2019, with the overall index ranging from 30·7 (28·6–33·0) on average in low-SDI countries to 83·4 (82·4–84·3) on average in high-SDI countries. Similarly large ranges between low-SDI and high-SDI countries, respectively, were estimated in the HAQ Index for the young (40·4–89·0), working (33·8–82·8), and post-working (30·4–79·1) groups. Absolute convergence in HAQ Index was estimated in the young group only. In contrast, divergence was estimated among the working and post-working groups, driven by slow progress in low-SDI countries.

Although major gaps remain across levels of social and economic development, convergence in the young group is an encouraging sign of reduced disparities in health-care access and quality. However, divergence in the working and post-working groups indicates that health-care access and quality is lagging at lower levels of social and economic development. To meet the needs of ageing populations, health systems need to improve health-care access and quality for working-age adults and older populations while continuing to realise gains among the young.
Original languageEnglish
Pages (from-to) e1715-e1743
Number of pages28
JournalThe Lancet Global Health
Issue number12
Early online date16 Nov 2022
Publication statusPublished - 1 Dec 2022

Bibliographical note


O Adetokunboh acknowledges support from Department of Science and Innovation and National Research Foundation. S Afzal acknowledges the institutional support of King Edward Medical University. S Aljunid acknowledges Department of Health Policy and Management, College of Public Health, Health Science Centre, Kuwait University for the approval and support to participate in this research project. M Ausloos, C Herteliu, and A 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. C Herteliu also acknowledges partial support by a grant of the Romanian Ministry of Research Innovation and Digitalization, MCID, project number ID-585-CTR-42-PFE-2021. T Bärnighausen was supported by the Alexander von Humboldt Foundation through the Alexander von Humboldt Professor award, funded by the Federal Ministry of Education and Research. B Bikbov acknowledges funding from the European Union's Horizon 2020 research and innovation programme under Marie Sklodowska-Curie grant agreement No. 703226. Institute of Applied Health Sciences; School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Scotland. The salary for N Ghith is covered by a grant from Novo Nordisk Foundation (NNF16OC0021856). V B Gupta acknowledges funding support from National Health and Medical Research Council (NHMRC) Australia. V K Gupta acknowledges funding support from National Health and Medical Research Council (NHMRC) Australia. T Joo acknowledges support from the National Research, Development and Innovation Office of Hungary under grant RRF-2.3.1-21-2022-00006 (Data-driven Health Division of Health Security National Laboratory). S Vittal Katikireddi acknowledges funding from a NRS Senior Clinical Fellowship (SCAF/15/02), the Medical Research Council (MC_UU_00022/2), and the Scottish Government Chief Scientist Office (SPHSU17). M N Khan acknowledges the support of Jatiya Kabi Kazi Nazrul Islam University, Mymensingh, Bangladesh. Y J Kim acknowledges support from the Research Management Centre, Xiamen University Malaysia [XMUMRF/2020-C6/ITCM/0004]. G Lucchetti is a grantee of the Brazilian National Council for Scientific and Technological Development Research Productivity - Level 1D. L Mantovani acknowledges support by Italian Ministry of Health Ricerca Corrente - IRCCS Multimedica. M Molokhia acknowledges support by the National Institute for Health Research Biomedical Research Center at Guy's and St Thomas' National Health Service Foundation Trust and King's College London. L Monasta reports support for the present manuscript from the Italian Ministry of Health on project Ricerca Corrente 34/2017 and payments made to the Institute for Maternal and Child Health IRCCS Burlo Garofolo. R Moreira acknowledges the CNPQ productivity grant (316607/2021-5). B R Nascimento is partially supported by CNPq (Research Productivity Grant, 312382/2019-7), the Edwards Lifesciences Foundation (Improving the prevention and detection of Heart Valve disease across the Lifespan, 2021), and FAPEMIG (grant APQ-000627-20). J R Padubidri acknowledges Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India for their constant support in conducting research. D Rasella reports financial support from the Spanish Ministry of Science and Innovation and State Research Agency through the Centro de Excelencia Severo Ochoa 2019-2023 programme (CEX2018-000806-S), and financial support from the Generalitat de Catalunya through the Centres de Recerca de Catalunya programme. U Saeed would like to acknowledge the International Center of Medical Sciences Research (ICMSR), Islamabad (44000), Pakistan. A M Samy acknowledges the support from Ain Shams University and the Egyptian Fulbright Mission Program. U Saeed would like to acknowledge Kasturba Medical College, Mangalore. Manipal Academy of Higher Education, Manipal for supporting research activities. R T-S is supported by the Spanish Ministry of Science and Innovation, Institute of Health Carlos III, CIBERSAM, INCLIVA (PID2021-129099OB-I00). D Vervoort is supported by the Canadian Institutes of Health Research (CIHR) Vanier Canada Graduate Scholarship. S B Zaman acknowledges receiving a scholarship from the Australian Government Research Training Program (RTP) in support of his academic career. Serbian part of this GBD contribution was co-financed through Grant OI 175 014 of the Ministry of Education Science and Technological Development of The Republic of Serbia. This work was supported, in whole or in part, by the Bill & Melinda Gates Foundation OPP1152504. Under the grant conditions of the Foundation, a Creative Commons Attribution 4.0 Generic License has already been assigned to the Author Accepted Manuscript version that might arise from this submission.

Bill & Melinda Gates Foundation.

Data Availability Statement

For detailed information regarding input data sources and to download the data used in these analyses, please visit the Global Health Data Exchange GBD 2019 website at


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