“The HAQ Index performance followed distinct geographical patterns in 2016 (figure 1), with most countries in the highest decile clustered in Europe or nearby (ie, Iceland), and almost all countries in the lowest decile located in sub-Saharan Africa. Exceptions to this pattern included Canada, Japan, Australia, and New Zealand in the tenth decile, and Afghanistan in the first decile. More heterogeneity emerged among the next deciles of performance (eg, USA, UK, Malta, Lebanon, Singapore, and South Korea, in the ninth decile; Cuba, Chile, Saudi Arabia, and Russia, in the eighth decile). Most Latin American countries scored between the fourth and sixth deciles, whereas southeast Asia featured a broader range, spanning from the seventh (Thailand and Sri Lanka) to third deciles (Cambodia, Indonesia, Laos, Myanmar, and Timor-Leste). By 2016, many sub-Saharan African countries improved their performance from 1990 and 2000 (appendix pp 113–14), such as South Africa and Botswana rising to the fourth decile, and several locations moving to the third decile (eg, Kenya, Rwanda, Namibia, Nigeria, Ghana). African countries that remained in the first decile since 1990 were generally concentrated in central and eastern sub-Saharan Africa.

“We applied the deciles set by national HAQ Index scores in 2016 to subnational locations (figure 2), and a more nuanced landscape surfaced regarding inequalities in personal health-care access and quality. China was in the eighth decile in 2016, and had provinces spanning from the tenth decile (Beijing 91·5, 95% UI 89·1–93·6) to the fourth decile (Tibet 48·0, 43·5–53·2), with a higher performance (ie, eighth and ninth deciles) among eastern provinces and lower (ie, fifth and sixth deciles) in western provinces. For India, which was in the third decile in 2016, subnational performance ranged from the sixth (Goa 64·8, 59·6–68·8; Kerala 63·9, 58·6–67·0) to the second deciles (Assam 34·0, 30·3–38·1; and Uttar Pradesh 34·9, 31·1–38·4). Brazil and Mexico, each in the sixth decile nationally for 2016, had variable subnational patterns. In Brazil, performance was as high as the eighth decile for the Federal District (75·4, 72·3–78·1), but most states, particularly northern ones, were in the fifth decile. Conversely, Mexico featured six states in the seventh decile, whereas most others were in the sixth decile; four states, all along Mexico’s southern border, fell within the fifth decile. Both occupying the ninth decile nationally, England and the USA had subnational locations spanning from the tenth to seventh deciles in 2016; Blackpool (79·7 [76·6–82·8]) had the lowest HAQ Index score in England and Mississippi (81·5 [78·6–84·2]) had the lowest score in the USA. The USA’s highest HAQ Index scores were limited to a subset of northeastern states, Minnesota, and Washington state, and higher performance was primarily dispersed across southern England. Nearly all Japanese prefectures occupied the top decile of HAQ Index performance in 2016. The appendix contains a more in-depth exploration of subnational trends over time by country (pp 115–28).

“Patterns of performance on the overall HAQ Index and health areas varied considerably across countries in 2016 (figure 3). Locations that scored approximately 90 or higher on the HAQ Index had generally high scores across broader causes, including vaccine-preventable diseases, infectious diseases and maternal and child health, and causes that require complex case management (eg, epilepsy, diabetes, and chronic kidney disease). Nonetheless, many of these countries had lower scores for cancers and some non-communicable diseases. Greater heterogeneity occurred across causes for countries that scored below 90 on the HAQ Index, though many locations achieved greater consistency, and high scores, for vaccine-preventable diseases and gastrointestinal causes for which surgery could avert death. For these countries, a mixture of relatively low values on cancers and some non-communicable diseases, and then comparably better performance on other health areas, was commonplace. Among countries with lower HAQ Index scores in 2016 (ie, lower than approximately 50), most fared poorly across health areas and recorded particularly low scores on cancers, some infectious causes like tuberculosis, and maternal and child health. Nonetheless, many still exceeded a score of 90 for some causes (eg, diphtheria, upper respiratory infections).”

Source: GBD 2016 Healthcare Access and Quality Collaborators. “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.” Lancet (London, England) vol. 391,10136 (2018): 2236-2271. doi:10.1016/S0140-6736(18)30994-2 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5986687/