Healthcare inequality between countries grows despite global improvements

First global study of its kind reveals quality and accessibility of healthcare around the world.
Image: Mapping personal healthcare access and quality worldwide in 2015

Global healthcare access and quality has improved since 1990, yet inequalities between the best and worst-performing countries have grown. Even among countries of similar development levels, there is wide variation, according to a new Global Burden of Disease study published in The Lancet.

The study developed a new index which measures the quality and accessibility of healthcare. The rating (scored 0-100) is based on death rates from 32 diseases that could be avoided by effective medical care in the country. The global collaboration of researchers, coordinated by the Institute of Health Metrics and Evaluation (IHME) based at the University of Washington, and including the London School of Hygiene & Tropical Medicine, assessed performance for 195 countries from 1990-2015. The results provide crucial data to help monitor progress on universal health coverage and identify local priorities for improving healthcare.

Globally, the index increased from 40.7 in 1990 to 53.7 in 2015 and 167 countries saw healthcare access and quality significantly improve. However, over the same timeframe, the divide between the best and worst-performing countries widened– ranging from 28.6 to 94.6 (66.0 point gap) in 2015.

Senior author, Professor Christopher Murray from the IHME at the University of Washington said: “Having a strong economy does not guarantee good health care. Having great medical technology doesn’t either. We know this because people are not getting the care that should be expected for diseases with established treatments.”

Overall in 2015, Western European countries generally scored highest, while those in sub-Saharan Africa and Oceania mainly scored lowest. But not all countries in the same region performed similarly. For example, within sub-Saharan Africa, 2015 healthcare performance in Cape Verde was among the middle of the table of all countries worldwide while Lesotho, Somalia and Chad were amongst the poorest-performing countries. While many countries in Western Europe alongside Canada, Japan and Australia were ranked in the top-performing group, the UK and USA were outpaced by their peers, ranking in the second-best group. The UK scored 84.6 in 2015 – an increase of 10.3 since 1990 – placing the UK in 30th worldwide.

Study co-author, Professor Martin McKee from the London School of Hygiene & Tropical Medicine, whose previous work helped inform the new index, said: “The UK has made consistent progress since 1990, but with a score of 85 it now lags behind many of its European neighbours. This includes Finland, Sweden, Spain (all 90) and Italy (89), all of which have health systems very similar to the British NHS and so are most directly comparable. The gap between what the UK achieves and what it would be expected to, given its level of development, is also wider than in other western European countries.

“The UK does well in some areas, including cerebrovascular disease (88), likely to reflect the quality of general practice, where high blood pressure is detected and treated and advances in acute management of stroke, especially in London, but it lags behind in outcomes of some cancers, a problem that has many causes but is often attributed to low levels of investment in specialist care.” 

Countries including South Korea, Turkey, Peru, China and the Maldives recorded some of the largest improvements showing that more rapid advances are possible than seen overall. Potential drivers of this may include the financial arrangements of the healthcare system, provider ownership and its governance. The authors note that further research will be needed to confirm this, which could then provide a model to help other countries improve.

The study is also the first of its kind to use sociodemographic data to analyse how healthcare improved in line with economic development in each country. The researchers compared each country’s healthcare quality and access performance rating with the rating it would be expected to have, based on its level of economic development. This gap helps illustrate the extent to which a country’s healthcare system could be improved, and compare countries at similar levels of development. There was huge variation for countries of similar development levels. Importantly, for 62 countries the gap between their actual and expected rating widened, particularly in southern sub-Saharan African countries.

Dr Heidi Larson, Associate Professor at the London School of Hygiene & Tropical Medicine and Director of European Initiatives at the IHME, said: "No matter where countries sit on the Socio-demographic Index, we cannot lose sight of the considerable inequities in access to care as well as quality of care within nations that need to be addressed."

The top performer was Andorra maintaining its ranking from 1990 and with a rating of 94.6 out of 100 in 2015. Other than Switzerland the rest of the top 5 performers were Nordic countries (1: Andorra (94.6), 2: Iceland (93.6), 3: Switzerland (91.8), 4: Sweden (90.5), 5: Norway (90.5)).

The authors noted that limited data in many lower income countries means that there may be greater uncertainty for some results. Additionally, they plan to extend the analysis to include public health intervention impact, as well as including an increased number of avoidable causes of death to account for recent medical advances (such as antiretroviral therapy for HIV) and causes with lower death rates.


GBD 2015 Healthcare Access and Quality Contributors Healthcare Access and Quality Index based on mortality from causes amenable to personal health care in 195 countries and territories, 1990–2015: a novel analysis from the Global Burden of Disease Study 2015. The Lancet. DOI: 10.1016/S0140-6736(17)30818-8

Short Courses

LSHTM's short courses provide opportunities to study specialised topics across a broad range of public and global health fields. From AMR to vaccines, travel medicine to clinical trials, and modelling to malaria, refresh your skills and join one of our short courses today.