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. FUNDING: Bill & Melinda Gates Foundation.

Five insights from the Global Burden of Disease Study 2019.

The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 provides a rules-based synthesis of the available evidence on levels and trends in health outcomes, a diverse set of risk factors, and health system responses. GBD 2019 covered 204 countries and territories, as well as first administrative level disaggregations for 22 countries, from 1990 to 2019. Because GBD is highly standardised and comprehensive, spanning both fatal and non-fatal outcomes, and uses a mutually exclusive and collectively exhaustive list of hierarchical disease and injury causes, the study provides a powerful basis for detailed and broad insights on global health trends and emerging challenges. GBD 2019 incorporates data from 281 586 sources and provides more than 3·5 billion estimates of health outcome and health system measures of interest for global, national, and subnational policy dialogue. All GBD estimates are publicly available and adhere to the Guidelines on Accurate and Transparent Health Estimate Reporting. From this vast amount of information, five key insights that are important for health, social, and economic development strategies have been distilled. These insights are subject to the many limitations outlined in each of the component GBD capstone papers.

The relationships between democratic experience, adult health, and cause-specific mortality in 170 countries between 1980 and 2016: an observational analysis.

BACKGROUND: Previous analyses of democracy and population health have focused on broad measures, such as life expectancy at birth and child and infant mortality, and have shown some contradictory results. We used a panel of data spanning 170 countries to assess the association between democracy and cause-specific mortality and explore the pathways connecting democratic rule to health gains. METHODS: We extracted cause-specific mortality and HIV-free life expectancy estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 and information on regime type from the Varieties of Democracy project. These data cover 170 countries and 46 years. From the Financing Global Health database, we extracted gross domestic product (GDP) per capita, also covering 46 years, and Development Assistance for Health estimates starting from 1990 and domestic health spending estimates starting from 1995. We used a diverse set of empirical methods-synthetic control, within-country variance decomposition, structural equation models, and fixed-effects regression-which together provide a robust analysis of the association between democratisation and population health. FINDINGS: HIV-free life expectancy at age 15 years improved significantly during the study period (1970-2015) in countries after they transitioned to democracy, on average by 3% after 10 years. Democratic experience explains 22·27% of the variance in mortality within a country from cardiovascular diseases, 16·53% for tuberculosis, and 17·78% for transport injuries, and a smaller percentage for other diseases included in the study. For cardiovascular diseases, transport injuries, cancers, cirrhosis, and other non-communicable diseases, democratic experience explains more of the variation in mortality than GDP. Over the past 20 years, the average country's increase in democratic experience had direct and indirect effects on reducing mortality from cardiovascular disease (-9·64%, 95% CI -6·38 to -12·90), other non-communicable diseases (-9·14%, -4·26 to -14·02), and tuberculosis (-8·93%, -2·08 to -15·77). Increases in a country's democratic experience were not correlated with GDP per capita between 1995 and 2015 (ρ=-0·1036; p=0·1826), but were correlated with declines in mortality from cardiovascular disease (ρ=-0·3873; p<0·0001) and increases in government health spending (ρ=0·4002; p<0·0001). Removal of free and fair elections from the democratic experience variable resulted in loss of association with age-standardised mortality from non-communicable diseases and injuries. INTERPRETATION: When enforced by free and fair elections, democracies are more likely than autocracies to lead to health gains for causes of mortality (eg, cardiovascular diseases and transport injuries) that have not been heavily targeted by foreign aid and require health-care delivery infrastructure. International health agencies and donors might increasingly need to consider the implications of regime type in their efforts to maximise health gains, particularly in the context of ageing populations and the growing burden of non-communicable diseases. FUNDING: Bloomberg Philanthropies and the Bill & Melinda Gates Foundation.

Health care and productivity costs for isolated tibia shaft fracture admissions in The Netherlands.

The aim of this study was to provide a detailed overview of age and gender specific health care costs and costs due to lost productivity for hospital admitted patients with an isolated tibia shaft fracture in The Netherlands between 2008 and 2012. Injury cases and length of hospital stay were extracted from the National Medical Registration. Information on extramural health care and work absence were retrieved from a patient follow-up survey on health care use. Medical costs included ambulance care, in- hospital care, general practitioner care, home care, physical therapy, and rehabilitation/nursing care. An incidence-based cost model was applied to calculate direct health care costs and lost productivity in 2012. Total direct health care costs for all patients admitted with a tibia shaft fracture (n = 1,635) were €13.6 million. Costs for productivity loss were € 23.0 million. Total costs (direct health care and lost productivity) per patient were highest for men aged 40-49 years mainly due to lost productivity, and for women aged > 80 years, due to high direct medical costs.

The early impact of the Covid-19 pandemic on the global and Turkish economy

Background/aim: Individuals infected by the Covid-19 potentially are at risk of health and economic well-being. Today, the Covid-19 is a global issue, and the world economy can be interpreted as almost at the standstill. In this context, this study aims to discuss the potential first reactions of short and long term global economic impacts of the pandemic through sectors by assessing its costs according to the data announced for both the world and Turkey. In addition, this study tries to put forth possible economic and political scenarios for the post-pandemic world. Materials and methods: This is a review article that summarizes the current reports and discussions about the economic consequences of this historical event, and tries to make some inferences considering them. Results: This pandemic has severe adverse effects on the employees, customers, supply chains and financial markets, in brief, most probably it will cause a global economic recession. Nevertheless, due to the uncertainty of the end of this pandemic, both the length and scale of this contraction are not predictable. Conclusion: It takes a while for the world economy to recover from the contraction. It seems that this pandemic will lead to a permanent shift in the world and its politics, especially in health, security, trade, employment, agriculture, manufacturing goods production and science policies. Since this new world might provide great opportunities for some countries that did not dominate world production before, governments should develop new strategies to adjust the new world order without much delay.

Forecasting life expectancy, years of life lost, and all-cause and cause-specific mortality for 250 causes of death: reference and alternative scenarios for 2016-40 for 195 countries and territories.

BACKGROUND: Understanding potential trajectories in health and drivers of health is crucial to guiding long-term investments and policy implementation. Past work on forecasting has provided an incomplete landscape of future health scenarios, highlighting a need for a more robust modelling platform from which policy options and potential health trajectories can be assessed. This study provides a novel approach to modelling life expectancy, all-cause mortality and cause of death forecasts -and alternative future scenarios-for 250 causes of death from 2016 to 2040 in 195 countries and territories. METHODS: We modelled 250 causes and cause groups organised by the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) hierarchical cause structure, using GBD 2016 estimates from 1990-2016, to generate predictions for 2017-40. Our modelling framework used data from the GBD 2016 study to systematically account for the relationships between risk factors and health outcomes for 79 independent drivers of health. We developed a three-component model of cause-specific mortality: a component due to changes in risk factors and select interventions; the underlying mortality rate for each cause that is a function of income per capita, educational attainment, and total fertility rate under 25 years and time; and an autoregressive integrated moving average model for unexplained changes correlated with time. We assessed the performance by fitting models with data from 1990-2006 and using these to forecast for 2007-16. Our final model used for generating forecasts and alternative scenarios was fitted to data from 1990-2016. We used this model for 195 countries and territories to generate a reference scenario or forecast through 2040 for each measure by location. Additionally, we generated better health and worse health scenarios based on the 85th and 15th percentiles, respectively, of annualised rates of change across location-years for all the GBD risk factors, income per person, educational attainment, select intervention coverage, and total fertility rate under 25 years in the past. We used the model to generate all-cause age-sex specific mortality, life expectancy, and years of life lost (YLLs) for 250 causes. Scenarios for fertility were also generated and used in a cohort component model to generate population scenarios. For each reference forecast, better health, and worse health scenarios, we generated estimates of mortality and YLLs attributable to each risk factor in the future. FINDINGS: Globally, most independent drivers of health were forecast to improve by 2040, but 36 were forecast to worsen. As shown by the better health scenarios, greater progress might be possible, yet for some drivers such as high body-mass index (BMI), their toll will rise in the absence of intervention. We forecasted global life expectancy to increase by 4·4 years (95% UI 2·2 to 6·4) for men and 4·4 years (2·1 to 6·4) for women by 2040, but based on better and worse health scenarios, trajectories could range from a gain of 7·8 years (5·9 to 9·8) to a non-significant loss of 0·4 years (-2·8 to 2·2) for men, and an increase of 7·2 years (5·3 to 9·1) to essentially no change (0·1 years [-2·7 to 2·5]) for women. In 2040, Japan, Singapore, Spain, and Switzerland had a forecasted life expectancy exceeding 85 years for both sexes, and 59 countries including China were projected to surpass a life expectancy of 80 years by 2040. At the same time, Central African Republic, Lesotho, Somalia, and Zimbabwe had projected life expectancies below 65 years in 2040, indicating global disparities in survival are likely to persist if current trends hold. Forecasted YLLs showed a rising toll from several non-communicable diseases (NCDs), partly driven by population growth and ageing. Differences between the reference forecast and alternative scenarios were most striking for HIV/AIDS, for which a potential increase of 120·2% (95% UI 67·2-190·3) in YLLs (nearly 118 million) was projected globally from 2016-40 under the worse health scenario. Compared with 2016, NCDs were forecast to account for a greater proportion of YLLs in all GBD regions by 2040 (67·3% of YLLs [95% UI 61·9-72·3] globally); nonetheless, in many lower-income countries, communicable, maternal, neonatal, and nutritional (CMNN) diseases still accounted for a large share of YLLs in 2040 (eg, 53·5% of YLLs [95% UI 48·3-58·5] in Sub-Saharan Africa). There were large gaps for many health risks between the reference forecast and better health scenario for attributable YLLs. In most countries, metabolic risks amenable to health care (eg, high blood pressure and high plasma fasting glucose) and risks best targeted by population-level or intersectoral interventions (eg, tobacco, high BMI, and ambient particulate matter pollution) had some of the largest differences between reference and better health scenarios. The main exception was sub-Saharan Africa, where many risks associated with poverty and lower levels of development (eg, unsafe water and sanitation, household air pollution, and child malnutrition) were projected to still account for substantive disparities between reference and better health scenarios in 2040. INTERPRETATION: With the present study, we provide a robust, flexible forecasting platform from which reference forecasts and alternative health scenarios can be explored in relation to a wide range of independent drivers of health. Our reference forecast points to overall improvements through 2040 in most countries, yet the range found across better and worse health scenarios renders a precarious vision of the future-a world with accelerating progress from technical innovation but with the potential for worsening health outcomes in the absence of deliberate policy action. For some causes of YLLs, large differences between the reference forecast and alternative scenarios reflect the opportunity to accelerate gains if countries move their trajectories toward better health scenarios-or alarming challenges if countries fall behind their reference forecasts. Generally, decision makers should plan for the likely continued shift toward NCDs and target resources toward the modifiable risks that drive substantial premature mortality. If such modifiable risks are prioritised today, there is opportunity to reduce avoidable mortality in the future. However, CMNN causes and related risks will remain the predominant health priority among lower-income countries. Based on our 2040 worse health scenario, there is a real risk of HIV mortality rebounding if countries lose momentum against the HIV epidemic, jeopardising decades of progress against the disease. Continued technical innovation and increased health spending, including development assistance for health targeted to the world's poorest people, are likely to remain vital components to charting a future where all populations can live full, healthy lives. FUNDING: Bill & Melinda Gates Foundation.

The global response and unmet actions for HIV and sex workers.

Female, male, and transgender sex workers continue to have disproportionately high burdens of HIV infection in low-income, middle-income, and high-income countries in 2018. 4 years since our Lancet Series on HIV and sex work, our updated analysis of the global HIV burden among female sex workers shows that HIV prevalence is unacceptably high at 10·4% (95% CI 9·5-11·5) and is largely unchanged. Comprehensive epidemiological data on HIV and antiretroviral therapy (ART) coverage are scarce, particularly among transgender women. Sustained coverage of treatment is markedly uneven and challenged by lack of progress on stigma and criminalisation, and sustained human rights violations. Although important progress has been made in biomedical interventions with pre-exposure prophylaxis and early ART feasibility and demonstration projects, limited coverage and retention suggest that sustained investment in community and structural interventions is required for sex workers to benefit from the preventive interventions and treatments that other key populations have. Evidence-based progress on full decriminalisation grounded in health and human rights-a key recommendation in our Lancet Series-has stalled, with South Africa a notable exception. Additionally, several countries have rolled back rights to sex workers further. Removal of legal barriers through the decriminalisation of sex work, alongside political and funding investments to support community and structural interventions, is urgently needed to reverse the HIV trajectory and ensure health and human rights for all sex workers.

Measuring the Economic Burden of Disease and Injury in Korea, 2015.

BACKGROUND: Disease burden can be represented by health-related parameters such as disability-adjusted life years and economic burden. Economic burden is an important index, as it estimates the maximum possible cost reduction if a disease is prevented. This study aimed to determine the economic burden of 238 diseases and 22 injuries in Korea in 2015. METHODS: Economic burden was estimated with a human resources approach from a social perspective, and direct and indirect costs were calculated from insurance claims data and a cause of death database. Direct costs were divided into medical costs (including hospital admission, outpatient visit, and medication use) and nonmedical costs (including transportation and caregiver costs). Indirect costs from lost productivity, either from the use of healthcare service or premature death, were analyzed. RESULTS: In 2015, the estimated economic burden was USD 133.7 billion (direct: USD 65.5 billion, indirect: USD 68.2 billion). The total cost of communicable diseases was USD 16.0 billion (11.9%); non-communicable diseases, USD 92.3 billion (69.1%); and injuries, USD 25.4 billion (19.0%). Self-harm had the highest costs (USD 8.3 billion), followed by low back pain (LBP, USD 6.6 billion). For men, self-harm had the highest cost (USD 7.1 billion), while LBP was the leading cost (USD 3.7 billion) for women. CONCLUSION: A high percentage of Korea's total socioeconomic disease burden is due to chronic diseases; however, unnoticed conditions such as infectious diseases, injuries, and LBP are high in certain age groups and differ by gender, emphasizing the need for targeted social interventions to manage and prevent disease risk factors.

Comparative Research for the Healthcare Budget and Burden of Disease in Perspective Resource Allocation.

BACKGROUND: Burden of disease can be used to prioritize the healthcare budget allocation. We analyzed the research and development (R&D) budget of the Ministry of Health and Welfare (MOHW) in 2018 and compared the results with those of the 2015 Korean National Burden of Disease (KNBD) study. METHODS: The 2018 MOHW R&D Project integrated implementation plan was used to analyze the R&D budget of the MOHW. The budget was allocated according to the KNBD disease group and according to the budget lines. The allocated budget was compared with the economic burden and the disability adjusted life years (DALYs) in 2015. Also, for budget targets for risk factors, DALYs of attributable risk factors were compared with corresponding budgets. RESULTS: In 2018, the MOHW major R&D budget of USD 435.1 million accounted for 3% of the total government budget. Within the disease specific R&D budget, 35.9% was allocated to communicable disease groups, 64.1% to non-communicable diseases, and 0% to injury and violence. Among level 2 disease groups, neoplasm was ranked first. Among risk factors, climate change and behavioral risk were targeted for R&D. CONCLUSIONS: It would be difficult to say that current R&D allocations focus to minimize the burden of disease. A mismatch was observed between the R&D budget and the burden of disease in terms of economic burden and DALYs. There was a similar finding for risk factors R&D. A novel approach for allocating government R&D funding that is based on the goal of minimizing the disease burden in the Korean population should be considered.

Use and Misuse of Cost-Effectiveness Analysis Thresholds in Low- and Middle-Income Countries: Trends in Cost-per-DALY Studies.

OBJECTIVES: To determine what thresholds are most often cited in the cost-effectiveness literature for low- and middle-income countries (LMICs), given various recommendations proposed and used in the literature to date, and thereafter to assess whether studies appropriately justified their use of threshold values. METHODS: We reviewed the contents of the Tufts Medical Center Global Health Cost-Effectiveness Analysis Registry, a repository of all English language cost-per-disability-adjusted life-year averted studies indexed in PubMed. Our review included all catalogued cost-per-disability-adjusted life-year studies published from 2000 through 2015. We restricted attention to studies that investigated interventions in LMICs. RESULTS: Our analysis identified 381 studies (80%) focused on LMICs. Of these studies, 250 (66%) cited the World Health Organization's 1 to 3 times gross domestic product per capita threshold. A full-text review of 60 (24%) of these articles (randomly selected) revealed that none justified use of this threshold in the particular country or countries studied beyond citing (generic) guideline documents. CONCLUSIONS: Cost-effectiveness analysis can help inform health care spending, but its value depends on incorporating assumptions that are valid for the applicable setting. Rather than rely on commonly used, generic economic thresholds, we encourage authors to use context-specific thresholds that reflect local preferences.

Profile and evolution of the Global Burden of Morbidity in the Maghreb (Tunisia,Morocco, Algeria). The Triple burden of morbidity.

BACKGROUND: The Global Burden of Disease (GBD) is an objective method of measurement of disease disability, allowing the quantification of a population's health status, the identification of its health needs, and the determination of its public health priorities. OBJECTIVES: To document the epidemiological transition in Maghreb countries (Tunisia, Morocco, Algeria) over the past three decades and to identify their priority health problems, which are responsible for a considerable burden of disability. METHODS: This is a data synthesis work of the Institute for Health Metrics and Evaluation (IHME) global burden of disease, through its project "GBD Compare Data Visualization". Data covering the period from 1990 to 2016, examined the three major categories of health problems "communicable, maternal, neonatal and nutritional diseases", "noncommunicable diseases" and "injuries", as well as the three types of risk: metabolic, environmental / professional and behavioral. RESULTS: Since 1990, cardiovascular diseases have consistently been the leading cause of death in the three Maghreb countries. During the period 1990-2016, and at varying speeds, the positions of communicable and neonatal diseases declined, while noncommunicable diseases (particularly cardiovascular diseases, cancers, mental disorders, diabetes and neurological disorders) increased significantly, to be at the top of the list of components of the global burden of disease.In 2016, road accidents have been ranked eighth in the ranking of the main components of the overall burden of morbidity in Tunisia and Morocco and ninth in Algeria. During the same period, the environmental and behavioral risk factors registered an overall decrease in the three Maghreb countries, in contrast to the metabolic risk factors that experienced a gradual and homogeneous increase in the Greater Maghreb. CONCLUSION: This GBD analysis confirmed the rather old and fairly advanced epidemiological transition in Maghreb countries, leading to a real "triple burden" threatening the stability and sustainability of national health systems. Hence the urgency of supporting the following five projects: the curriculum reform of the faculties of health sciences, the development of the second line of care, the participative management of health services, universal health coverage and the implementation of a comprehensive and integrated strategy for prevention and health promotion.

The state of gene therapy research in Africa, its significance and implications for the future.

Gene therapy has made impressive recent progress and has potential for treating a wide range of diseases, many of which are important to Africa. However, as a result of lack of direct public funding and skilled personnel, direct research on gene therapy in Africa is currently limited and resources to support the endeavor are modest. A strength of the technology is that it is based on principles of rational design, and the tools of gene therapy are now highly versatile. For example gene silencing and gene editing may be used to disable viral genes for therapeutic purposes. Gene therapy may thus lead to cure from infections with HIV-1, hepatitis B virus and Ebola virus, which are of significant public health importance in Africa. Although enthusiasm for gene therapy is justified, significant challenges to implementing the technology remain. These include ensuring efficient delivery of therapeutic nucleic acids to target cells, limiting unintended effects, cost and complexity of treatment regimens. In addition, implementation of effective legislation that will govern gene therapy research will be a challenge. Nevertheless, it is an exciting prospect that gene therapy should soon reach the mainstream of medical management. Participation of African researchers in the exciting developments is currently limited, but their involvement is important to address health problems, develop capacity and enhance economic progress of the continent.

The direct and indirect costs associated with endometriosis: a systematic literature review.

STUDY QUESTION: What is the economic burden of endometriosis? SUMMARY ANSWER: The identified studies indicate that there is a significant economic burden associated with endometriosis, as observed by both direct and indirect costs. WHAT IS KNOWN ALREADY: Two previous systematic literature reviews suggested that there were considerable direct costs associated with endometriosis and there was a general lack of measurement of indirect costs. STUDY DESIGN, SIZE, DURATION: We performed a systematic literature review. MEDLINE and EMBASE databases from 2000 to 2013 were searched. The literature search was limited to human studies of patients with endometriosis. Papers in languages other than English were excluded. PARTICIPANTS/MATERIALS, SETTING, METHODS: Studies reporting direct or indirect costs among patients with endometriosis were considered for inclusion. Direct costs included inpatient, outpatient, surgery, drug and other healthcare service cost. Indirect costs were related to absenteeism and presenteeism (lost productivity at work). MAIN RESULTS AND THE ROLE OF CHANCE: After evaluating the 1396 articles in the search results, 12 primary studies that reported direct or indirect costs associated with endometriosis were identified and included in the data extraction. Three of the studies were conducted in the USA, one study each was conducted in Austria, Belgium, Brazil, Canada, Finland, Germany and Italy, and two studies included data from 10 countries. Significant variability was observed in the reviewed studies in methodology, including data source, cost components considered and study perspective. Estimates of total direct costs ranged from $1109 per patient per year in Canada to $12 118 per patient per year in the USA. Indirect costs of endometriosis ranged from $3314 per patient per year in Austria to $15 737 per patient per year in the USA. LIMITATIONS, REASONS FOR CAUTION: The studies identified in the systematic literature review varied greatly by study methodology as well as by country owing to different healthcare systems and costs of healthcare services, which contributed to large variations in the direct and indirect cost estimates. WIDER IMPLICATIONS OF THE FINDINGS: A majority of the studies we found were published after the periods covered in the prior systematic literature reviews, which provided substantial contributions to an understanding of the economic burden of endometriosis, especially in the area of indirect costs. The long-term burden of endometriosis following diagnosis is still under-studied, which is a concern given the chronic nature of the disease and the substantial recurrence of endometriosis symptoms. STUDY FUNDING/COMPETING INTERESTS: This study was funded by AbbVie, which also develops the oral GnRH antagonist elagolix (in collaboration with Neurocrine Biosciences) for the management of endometriosis and uterine fibroids. A.M.S. is an employee of AbbVie and currently owns AbbVie stocks. H.Y., E.X.D. and C.K. are employees of Analysis Group, Inc., which has received consultancy fees from AbbVie. C.W. is a Clinical Professor at the Department Obstetrics and Gynecology at Georgetown University in Washington, DC, USA and has served in a consulting role to AbbVie for this project.

Gazing through time and beyond the health sector: Insights from a system dynamics model of cardiovascular disease in Australia.

OBJECTIVE: To construct a whole-of-system model to inform strategies that reduce the burden of cardiovascular disease (CVD) in Australia. METHODS: A system dynamics model was developed with a multidisciplinary modelling consortium. The model population comprised Australians aged 40 years and over, and the scope encompassed acute and chronic CVD as well as primary and secondary prevention. Health outcomes were CVD-related deaths and hospitalisations, and economic outcomes were the net benefit from both the healthcare system and societal perspectives. The eight strategies broadly included creating social and physical environments supportive of a healthy lifestyle, increasing the use of preventive treatments, and improving systems response to acute CVD events. The effects of strategies were estimated as relative differences to the business-as-usual between 2019-2039. Probabilistic sensitivity analysis produced uncertainty intervals of interquartile ranges (IQR). FINDINGS: The greatest reduction in CVD-related deaths was seen in strategies that improve systems response to acute CVD events (8.9%, IQR: 7.7-10.2%), yet they resulted in an increase in CVD-related hospitalisations due to future recurrent admissions (1.6%, IQR: 0.1-2.3%). This flow-on effect highlighted the importance of addressing underlying CVD risks. On the other hand, strategies targeting the broad environment that supports a healthy lifestyle were effective in reducing both hospitalisations (7.1%; IQR: 5.0-9.5%) and deaths (8.1% reduction; IQR: 7.1-8.9%). They also produced an economic net benefit of AU$43.3 billion (IQR: 37.7-48.7) using a societal perspective, largely driven by productivity gains. Overall, strategic planning to reduce the burden of CVD should consider the varying effects of strategies over time and beyond the health sector.

Economic impact of tuberculosis mortality in 120 countries and the cost of not achieving the Sustainable Development Goals tuberculosis targets: a full-income analysis.

BACKGROUND: The tuberculosis targets for the UN Sustainable Development Goals (SDGs) call for a 90% reduction in tuberculosis deaths by 2030, compared with 2015, but meeting this target now seems highly improbable. To assess the economic impact of not meeting the target until 2045, we estimated full-income losses in 120 countries, including those due to excess deaths resulting from COVID-19-related disruptions to tuberculosis services, for the period 2020-50. METHODS: Annual mortality risk changes at each age in each year from 2020 to 2050 were estimated for 120 countries. This risk change was then converted to full-income risk by calculating a population-level mortality risk change and multiplying it by the value of a statistical life-year in each country and year. As a comparator, we assumed that current rates of tuberculosis continue to decline through the period of analysis. We calculated the full-income losses, and mean life expectancy losses per person, at birth and at age 35 years, under scenarios in which the SDG targets are met in 2030 and in 2045. We defined the cost of inaction as the difference in full-income losses and tuberculosis mortality between these two scenarios. FINDINGS: From 2020 to 2050, based on the current annual decrease in tuberculosis deaths of 2%, 31·8 million tuberculosis deaths (95% uncertainty interval 25·2 million-39·5 million) are estimated to occur, corresponding to an economic loss of US$17·5 trillion (14·9 trillion-20·4 trillion). If the SDG tuberculosis mortality target is met in 2030, 23·8 million tuberculosis deaths (18·9 million-29·5 million) and $13·1 trillion (11·2 trillion-15·3 trillion) in economic losses can be avoided. If the target is met in 2045, 18·1 million tuberculosis deaths (14·3 million-22·4 million) and $10·2 trillion (8·7 trillion-11·8 trillion) can be avoided. The cost of inaction of not meeting the SDG tuberculosis mortality target until 2045 (vs 2030) is, therefore, 5·7 million tuberculosis deaths (5·1 million-8·1 million) and $3·0 trillion (2·5 trillion-3·5 trillion) in economic losses. COVID-19-related disruptions add $290·3 billion (260·2 billion-570·1 billion) to this cost. INTERPRETATION: Failure to achieve the SDG tuberculosis mortality target by 2030 will lead to profound economic and health losses. The effects of delay will be greatest in sub-Saharan Africa. Affected countries, donor nations, and the private sector should redouble efforts to finance tuberculosis programmes and research because the economic dividend of such strategies is likely to be substantial. FUNDING: None.

Burden of disease among the world's poorest billion people: An expert-informed secondary analysis of Global Burden of Disease estimates.

BACKGROUND: The health of populations living in extreme poverty has been a long-standing focus of global development efforts, and continues to be a priority during the Sustainable Development Goal era. However, there has not been a systematic attempt to quantify the magnitude and causes of the burden in this specific population for almost two decades. We estimated disease rates by cause for the world's poorest billion and compared these rates to those in high-income populations. METHODS: We defined the population in extreme poverty using a multidimensional poverty index. We used national-level disease burden estimates from the 2017 Global Burden of Disease Study and adjusted these to account for within-country variation in rates. To adjust for within-country variation, we looked to the relationship between rates of extreme poverty and disease rates across countries. In our main modeling approach, we used these relationships when there was consistency with expert opinion from a survey we conducted of disease experts regarding the associations between household poverty and the incidence and fatality of conditions. Otherwise, no within-country variation was assumed. We compared results across multiple approaches for estimating the burden in the poorest billion, including aggregating national-level burden from the countries with the highest poverty rates. We examined the composition of the estimated disease burden among the poorest billion and made comparisons with estimates for high-income countries. RESULTS: The composition of disease burden among the poorest billion, as measured by disability-adjusted life years (DALYs), was 65% communicable, maternal, neonatal, and nutritional (CMNN) diseases, 29% non-communicable diseases (NCDs), and 6% injuries. Age-standardized DALY rates from NCDs were 44% higher in the poorest billion (23,583 DALYs per 100,000) compared to high-income regions (16,344 DALYs per 100,000). Age-standardized DALY rates were 2,147% higher for CMNN conditions (32,334 DALYs per 100,000) and 86% higher for injuries (4,182 DALYs per 100,000) in the poorest billion, compared to high-income regions. CONCLUSION: The disease burden among the poorest people globally compared to that in high income countries is highly influenced by demographics as well as large disparities in burden from many conditions. The comparisons show that the largest disparities remain in communicable, maternal, neonatal, and nutritional diseases, though NCDs and injuries are an important part of the "unfinished agenda" of poor health among those living in extreme poverty.

Epidemiology of paediatric injuries in Nepal: evidence from emergency department injury surveillance.

BACKGROUND: Globally, injuries cause >5 million deaths annually and children and young people are particularly vulnerable. Injuries are the leading cause of death in people aged 5-24 years and a leading cause of disability. In most low-income and middle-income countries where the majority of global child injury burden occurs, systems for routinely collecting injury data are limited. METHODS: A new model of injury surveillance for use in emergency departments in Nepal was designed and piloted. Data from patients presenting with injuries were collected prospectively over 12 months and used to describe the epidemiology of paediatric injury presentations. RESULTS: The total number of children <18 years of age presenting with injury was 2696, representing 27% of all patients presenting with injuries enrolled. Most injuries in children presenting to the emergency departments in this study were unintentional and over half of children were <10 years of age. Falls, animal bites/stings and road traffic injuries accounted for nearly 75% of all injuries with poisonings, burns and drownings presenting proportionately less often. Over half of injuries were cuts, bites and open wounds. In-hospital child mortality from injury was 1%. CONCLUSION: Injuries affecting children in Nepal represent a significant burden. The data on injuries observed from falls, road traffic injuries and injuries related to animals suggest potential areas for injury prevention. This is the biggest prospective injury surveillance study in Nepal in recent years and supports the case for using injury surveillance to monitor child morbidity and mortality through improved data.