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Measuring the health-related Sustainable Development Goals in 188 countries: a baseline analysis from the Global Burden of Disease Study 2015GBD 2015 SDG Collaborators*

SummaryBackground In September, 2015, the UN General Assembly established the Sustainable Development Goals (SDGs). The SDGs specify 17 universal goals, 169 targets, and 230 indicators leading up to 2030. We provide an analysis of 33 health-related SDG indicators based on the Global Burden of Diseases, Injuries, and Risk Factors Study 2015 (GBD 2015).

Methods We applied statistical methods to systematically compiled data to estimate the performance of 33 health-related SDG indicators for 188 countries from 1990 to 2015. We rescaled each indicator on a scale from 0 (worst observed value between 1990 and 2015) to 100 (best observed). Indices representing all 33 health-related SDG indicators (health-related SDG index), health-related SDG indicators included in the Millennium Development Goals (MDG index), and health-related indicators not included in the MDGs (non-MDG index) were computed as the geometric mean of the rescaled indicators by SDG target. We used spline regressions to examine the relations between the Socio-demographic Index (SDI, a summary measure based on average income per person, educational attainment, and total fertility rate) and each of the health-related SDG indicators and indices.

Findings In 2015, the median health-related SDG index was 59∙3 (95% uncertainty interval 56∙8–61∙8) and varied widely by country, ranging from 85∙5 (84∙2–86∙5) in Iceland to 20∙4 (15∙4–24∙9) in Central African Republic. SDI was a good predictor of the health-related SDG index (r²=0∙88) and the MDG index (r²=0∙92), whereas the non-MDG index had a weaker relation with SDI (r²=0∙79). Between 2000 and 2015, the health-related SDG index improved by a median of 7∙9 (IQR 5∙0–10∙4), and gains on the MDG index (a median change of 10∙0 [6∙7–13∙1]) exceeded that of the non-MDG index (a median change of 5∙5 [2∙1–8∙9]). Since 2000, pronounced progress occurred for indicators such as met need with modern contraception, under-5 mortality, and neonatal mortality, as well as the indicator for universal health coverage tracer interventions. Moderate improvements were found for indicators such as HIV and tuberculosis incidence, minimal changes for hepatitis B incidence took place, and childhood overweight considerably worsened.

Interpretation GBD provides an independent, comparable avenue for monitoring progress towards the health-related SDGs. Our analysis not only highlights the importance of income, education, and fertility as drivers of health improvement but also emphasises that investments in these areas alone will not be suffi cient. Although considerable progress on the health-related MDG indicators has been made, these gains will need to be sustained and, in many cases, accelerated to achieve the ambitious SDG targets. The minimal improvement in or worsening of health-related indicators beyond the MDGs highlight the need for additional resources to eff ectively address the expanded scope of the health-related SDGs.

Funding Bill & Melinda Gates Foundation.

Copyright The Authors(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY license.

BackgroundIn September, 2015, the UN General Assembly adopted “Transforming our World: The 2030 Agenda for Sustainable Development”, a resolution outlining a new framework to form the cornerstone of the sustainable development agenda for the period leading up to 2030.1 This new framework replaced the Millennium Development Goal (MDG) framework that expired in 2015, establishing 17 universal goals and 169 targets referred to as the Sustainable Development Goals (SDGs). The SDGs substantially broaden the development agenda beyond the MDGs and are expected to frame UN member state

policies over the next 15 years. To measure progress towards achieving the goals, the UN Statistical Commission created the Inter-Agency and Expert Group on Sustainable Development Goal Indicators (IAEG-SDGs) with a mandate to draft an indicator framework that aligns with the targets. The IAEG-SDGs announced a total of 230 indicators to measure achievement of the 169 targets.2 Health is a core dimension of the SDGs; goal 3 aims to “ensure healthy lives and promote wellbeing for all at all ages”. Health-related indicators—ie, indicators directly pertaining to health services, health outcomes, and environmental, occupational, behavioural, or metabolic

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*Collaborators listed at the end of the Article

Correspondence to:Prof Christopher J L Murray, University of Washington, Institute for Health Metrics and Evaluation, 2301 5th Avenue, Suite 600, Seattle, WA 98121, USAcjlm@uw.edu

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risks with well established causal connections to health—are also present in ten of the other 16 goals.3,4 Across these 11 goals, there are 28 health-related targets with a total of 47 health-related indicators.

The SDGs were developed through a highly consultative and iterative process that included multiple meetings with expert groups, civil society, and governments. However, the process of developing the SDGs and the accompanying goals, targets, and indicators has not been without its critics. In both scientifi c settings and the news media, the common refrain has been that the SDGs are a long list of vague goals that lack clear, realistic, and measurable targets and indicators,5–11 and that they are not accompanied by a clear theory of change12 articulating how the pieces fi t together.3 In view of the potential importance of the SDGs in directing national policies and donor investments, there has also been intense debate about the selection of targets and indicators;12 despite the lengthy list, some think that the SDGs are missing key areas of development, ranging from prohibition of forced labour13 to improvement of mental health.14–16 Concerns have also been expressed about the feasibility of measuring the 230 proposed indicators.5,6,17 Indeed, measurement of countries’ current status and progress towards meeting the SDG targets will be an enormous task and will require collective action across a range of national and international organisations, both governmental and non-governmental. The diffi culties of measurement are also further compounded by persistent problems of data availability, quality, and comparability across a host of indicators.4,18 Furthermore, measurement of development indicators is accompanied by a high potential for political entanglement, which can lead to distorted estimates.19–22 Independent monitoring of the SDG indicators will be crucial if they are to be used to accurately evaluate progress to ensure accountability and drive national and international development agendas towards meeting the SDGs.4,23–26

Despite these concerns, increasing work has been done in the past decade to generate independent, comparable, valid, and consistent measurements of development indicators.27–32 To measure progress on the SDGs, these existing eff orts will need to be leveraged, particularly those that provide comparable assessments of health outcomes and risks across countries and over time. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) is a primary example of such an initiative. GBD is an open, collaborative, independent study to comprehensively measure epidemiological levels and trends of disease and risk factor burden worldwide, with more than 1870 individual collaborators from 124 countries and three territories across the full range of development. GBD uses a highly standardised approach to overcome challenges of inconsistent coding and indicator defi nitions across countries, missing and confl icting data, and time lags in measurement and estimation. Of the 47 health-related indicators included as part of the SDGs, estimates for 33 indicators are presently included as part of GBD. The GBD study also has several mechanisms to ensure independence, including the GBD Scientifi c Council that meets regularly to review all methods and major data changes, and the Independent Advisory Committee that meets twice yearly to review GBD progress and provide recommendations for strengthening GBD estimates.33

In this analysis, while acknowledging the continued debate about the structure, selection, and construction of SDG indicators, we used the GBD study to assess the current status of these 33 health-related SDG indicators. With this baseline assessment, we developed and estimated a summary indicator for the health-related SDG indicators and documented historical trends for this summary indicator. With the GBD results, we identifi ed countries with the largest improvements between 1990 and 2015 to inform roadmaps and provide a basis for monitoring the health-related SDG indicators.

Research in context

Evidence before this studySince the adoption of the Sustainable Development Goals (SDGs) in September, 2015, demand to establish independent, robust avenues for monitoring progress for the SDGs has escalated. However, substantial challenges exist in undertaking comprehensive and comparable assessments of health-related SDG indicators to monitor and guide development agendas and health policy implementation.

Added value of this studyThe Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) features more than 1870 collaborators from 124 countries and three territories and provides an independent analytical platform through which levels of health-related SDG indicators can be assessed across geographies and over time in a

comparable manner. Drawing from GBD, we provide the measurement of 33 of the 47 health-related SDG indicators and introduce an overall health-related SDG index for 188 countries from 1990 to 2015.

Implications of all the available evidenceGBD and its analytical framework allow detailed analyses of country-level performance across health-related SDG indicators and over time. This information can be used to identify high-performing and low-performing countries, inform policy decisions, guide resource allocation, and monitor progress towards the health-related SDGs. The varied historical progress in improving a subset of health-related SDG indicators and rising prevalence of risks such as child overweight underscores the complex health landscape the world faces in the SDG era.

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MethodsOverview of GBDGBD is an annual eff ort to measure the health of populations at regional, country, and selected subnational levels.33 GBD produces estimates of mortality and morbidity by cause, age, sex, and country for the period 1990 to the most recent year, refl ecting all available data sources adjusted for bias. GBD also measures many health system characteristics, risk factor exposure, and mortality and morbidity attributable to these risks. In addition to providing highly detailed standardised information for many outcomes and risks, various summary measures are also computed, including disability-adjusted life-years (DALYs) and healthy life expectancy. For the present analysis, we used estimates from GBD 2015 to provide a baseline assessment for 188 countries. Further details on GBD 2015, which covers 1990–2015, are available elsewhere.34–39

Indicators, defi nitions, and measurement approachWe defi ned health-related SDG indicators as indicators for health services, health outcomes, and environmental, occupational, behavioural, and metabolic risks with well established causal connections to health. Many of the 47 health-related SDG indicators selected by the IAEG-SDGs are produced as part of GBD. Table 1 outlines the ten goals, corresponding to 21 health-related targets and 33 health-related indicators included in this present iteration of GBD. This table also outlines the defi nition of the indicator used in this analysis; detailed descriptions of the estimation methods and data sources are given in the methods appendix pp 10–311. For the 14 health-related indicators that were not included in this analysis, their prospects for measurement in future iterations of GBD are described in table 2.

Direct outputs of GBD that are health-related SDG indicators include mortality disaggregated by age (under-5 and neonatal) and cause (maternal, cardiovascular disease, cancer, diabetes, chronic respiratory diseases, road injuries, self-harm, un inten-tion al poisonings, exposure to forces of nature, inter-personal violence, and collective violence and legal inter vention [ie, deaths due to law enforcement actions, irrespective of their legality]), as well as disease incidence (HIV, malaria, tuberculosis, and hepatitis B) and prevalence (neglected tropical diseases). The GBD comparative risk assessment includes measurement of exposure prevalence included as health-related SDG indicators (under-5 stunting, wasting, and overweight; tobacco smoking; harmful alcohol use; intimate partner violence; unsafe water, sanitation, and hygiene; household air pollution; and ambient particulate matter pollution), as well as deaths or disease burden attributable to risk factors selected as health-related SDG indicators (unsafe water, sanitation, and hygiene; household air pollution and ambient particulate matter pollution; and occupational risks).

Underlying GBD outputs are a range of additional health determinants that contribute to the estimation of morbidity and mortality, for which data are systematically compiled and estimates are produced. For example, GBD comprehensively analyses data from household surveys on vaccine coverage and combines survey estimates with reported administrative data to produce time series of vaccine coverage for all countries from 1990 to 2015. Estimates of vaccine coverage are then included as predictors of vaccine-preventable morbidity and mortality in GBD. Additional health indicators produced as part of GBD and included as health-related SDG indicators in this analysis are: met need with modern contraception among women of reproductive age, adolescent birth rate, skilled birth attendance coverage, and universal health coverage (UHC) tracer interventions. For UHC tracer interventions, we developed an index based on the geometric mean of the coverage of a set of UHC tracer interventions: met need with modern contraception; antenatal care (one or more visits and four or more visits); skilled birth attendance coverage; in-facility delivery rates; vaccination coverage (three doses of diphtheria–pertussis–tetanus, measles vaccine, and three doses of oral polio vaccine or inactivated polio vaccine); tuberculosis case detection rate; coverage of antiretroviral therapy for populations living with HIV, and coverage of insecticide-treated nets for malaria-endemic countries.

For selected indicators proposed by the IAEG-SDGs, we made modifi cations to the defi nition for clarity or on the basis of the defi nition used in GBD (table 1). For example, Indicator 2.2.2 proposes a measure of malnutrition that combined prevalence of wasting and overweight among children under age 5 years. As childhood wasting and overweight have very diff erent determinants, we opted to report them separately. For childhood overweight, we report prevalence in children aged 2–4 years, the defi nition used in GBD based on thresholds set by the International Obesity Task Force.40

Further details on the estimation and data sources used for all indicators, compliant with Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER),41,42 are included in the methods appendix pp 10–311.

Health-related SDG, health-related MDG, and health-related non-MDG indicesTo identify broad patterns and more easily track general progress, we developed an overall health-related SDG index that is a function of the 33 health-related SDG indicators (referred to as the health-related SDG index). We also constructed two related indices: one refl ecting the SDG health-related indicators previously included in the MDG monitoring framework (referred to as the MDG index) and one refl ecting SDG health-related indicators not included in the MDGs (referred to as the non-MDG index).

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Health-related SDG indicator

Defi nition used in this analysis

Further details Inclusion in MDG or non-MDG index

Goal 1: End poverty in all its forms everywhere

Target 1.5: By 2030, build the resilience of the poor and those in vulnerable situations and reduce their exposure and vulnerability to climate-related extreme events and other economic, social and environmental shocks, and disasters

Disaster (1.5.1; same as Indicators 11.5.1 and 13.1.2)

Age-standardised death rate due to exposure to forces of nature, per 100 000 population

Existing datasets do not comprehensively measure missing people and people aff ected by natural disasters. We revised this indicator to exposure to forces of nature and reported in age-standardised rates

Non-MDG

Goal 2: End hunger, achieve food security and improved nutrition, and promote sustainable agriculture

Target 2.2: By 2030, end all forms of malnutrition, including achieving, by 2025, the internationally agreed targets on stunting and wasting in children under 5 years of age, and address the nutritional needs of adolescent girls, pregnant and lactating women, and older persons

Stunting (2.2.1) Prevalence of stunting in children under age 5 years, %

Stunting is defi ned as below –2 SDs from the median height-for-age of the reference population. No indicator modifi cations required

MDG

Target 2.2 (as above) Wasting (2.2.2a) Prevalence of wasting in children under age 5 years, %

Wasting is defi ned as below –2 SDs from the median weight-for-height of the reference population. We separated reporting for indicator 2.2.2 into wasting (2.2.2a) and overweight (2.2.2b)

MDG

Target 2.2 (as above) Overweight (2.2.2b) Prevalence of overweight in children aged 2–4 years, %

We used the IOTF thresholds because the WHO cutoff at age 5 years can lead to an artifi cial shift in prevalence estimates when the analysis covers more age groups. Furthermore, considerably more studies use IOTF cutoff s than WHO cutoff s, which allowed us to build a larger database for estimating child overweight. We separated reporting for indicator 2.2.2 into wasting (2.2.2a) and overweight (2.2.2b)

Non-MDG

Goal 3: Ensure healthy lives and promote wellbeing for all at all ages

Target 3.1: By 2030, reduce the global maternal mortality ratio to less than 70 per 100 000 livebirths

Maternal mortality ratio (3.1.1)

Maternal deaths per 100 000 livebirths

No indicator modifi cations required MDG

Target 3.1 (as above) Skilled birth attendance (3.1.2)

Proportion of births attended by skilled health personnel (doctors, nurses, midwives, or country-specifi c medical staff [eg, clinical offi cers]), %

No indicator modifi cations required MDG

Target 3.2: By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1000 livebirths and under-5 mortality to at least as low as 25 per 1000 livebirths

Under-5 mortality (3.2.1)

Probability of dying before age 5 years per 1000 livebirths

No indicator modifi cations required MDG

Target 3.2 (as above) Neonatal mortality (3.2.2)

Probability of dying during the fi rst 28 days of life per 1000 livebirths

No indicator modifi cations required MDG

Target 3.3: By 2030, end the epidemics of AIDS, tuberculosis, malaria, and neglected tropical diseases and combat hepatitis, water-borne diseases, and other communicable diseases

HIV (3.3.1) Age-standardised rate of new HIV infections, per 1000 population

We revised this indicator to HIV incidence of all populations and reported in age-standardised rates

MDG

Target 3.3 (as above) Tuberculosis (3.3.2) Age-standardised rate of new and relapsed tuberculosis cases, per 1000 population

No indicator modifi cations required MDG

Target 3.3 (as above) Malaria (3.3.3) Age-standardised rate of malaria cases, per 1000 population

No indicator modifi cations required MDG

Target 3.3 (as above) Hepatitis B (3.3.4) Age-standardised rate of hepatitis B incidence, per 100 000 population

No indicator modifi cations required Non-MDG

Target 3.3 (as above) Neglected tropical diseases (3.3.5)

Age-standardised prevalence of neglected tropical diseases, per 100 000 population

People requiring interventions against neglected tropical diseases are not well defi ned; thus, we revised this indicator to the sum of the prevalence of 14 neglected tropical diseases currently measured in GBD: African trypanosomiasis, Chagas disease, cystic echinococcosis, cysticerosis, dengue, food-borne trematodiases, intestinal nematode infections, leishmaniasis, leprosy, lymphatic fi lariasis, onchocerciasis, rabies, schistosomiasis, and trachoma

Non-MDG

(Table 1 continues on next page)

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Health-related SDG indicator

Defi nition used in this analysis

Further details Inclusion in MDG or non-MDG index

(Continued from previous page)

Target 3.4: By 2030, reduce by one-third premature mortality from NCDs through prevention and treatment, and promote mental health and wellbeing

NCDs (3.4.1) Age-standardised death rate due to cardiovascular disease, cancer, diabetes, and chronic respiratory disease in populations aged 30–70 years, per 100 000 population

No indicator modifi cations required Non-MDG

Target 3.4 (as above) Suicide (3.4.2) Age-standardised death rate due to self-harm, per 100 000 population

No indicator modifi cations required Non-MDG

Target 3.5: Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol

Alcohol (3.5.2) Risk-weighted prevalence of alcohol consumption, as measured by the SEV for alcohol use, %

We revised this indicator to include six categories of alcohol consumption because national alcohol consumption per person does not capture the distribution of use. The SEV for alcohol use is based on two primary dimensions and subcategories of each: individual-level drinking (current drinkers, lifetime drinkers, lifetime abstainers, and alcohol consumption by current drinkers) and drinking patterns (binge drinkers and frequency of binge drinks). The SEV then weights these categories with their corresponding relative risks, which translates to a risk-weighted prevalence on a scale of 0% (no risk in the population) to 100% (the entire population experiences maximum risk associated with alcohol consumption)

Non-MDG

Target 3.6: By 2020, halve the number of global deaths and injuries from road traffi c accidents

Road injuries (3.6.1) Age-standardised death rate due to road traffi c injuries, per 100 000 population

No indicator modifi cations required Non-MDG

Target 3.7: By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes

Family planning need met, modern contraception (3.7.1)

Proportion of women of reproductive age (15–49 years) who have their need for family planning satisfi ed with modern methods, % women aged 15–49 years

No indicator modifi cations required MDG

Target 3.7 (as above) Adolescent birth rate (3.7.2)

Birth rates for women aged 10–14 years and women aged 15–19 years, number of livebirths per 1000 women aged 10–14 years and women aged 15–19 years

No indicator modifi cations required MDG

Target 3.8: Achieve universal health coverage, including fi nancial risk protection, access to quality essential health-care services and access to safe, eff ective, quality, and aff ordable essential medicines and vaccines for all

Universal health coverage tracer (3.8.1)

Coverage of universal health coverage tracer interventions for prevention and treatment services, %

Tracer interventions included immunisation coverage (ie, coverage of three doses of diphtheria–pertussis–tetanus, measles vaccine, and three doses of oral polio vaccine or inactivated polio vaccine), met need with modern contraception, antenatal care coverage (one or more visits and four or more visits), skilled birth attendance, in-facility delivery rates, coverage of antiretroviral therapy for people living with HIV, tuberculosis case detection rate, and coverage of insecticide-treated nets in malaria-endemic countries

MDG

Target 3.9: By 2030, substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water, and soil pollution and contamination

Air pollution mortality (3.9.1)

Age-standardised death rate attributable to household air pollution and ambient air pollution, per 100 000 population

No indicator modifi cations required Non-MDG

Target 3.9 (as above) WaSH mortality (3.9.2)

Age-standardised death rate attributable to unsafe WaSH, per 100 000 population

No indicator modifi cations required Non-MDG

Target 3.9 (as above) Poisons (3.9.3) Age-standardised death rate due to unintentional poisonings, per 100 000 population

No indicator modifi cations required Non-MDG

(Table 1 continues on next page)

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Health-related SDG indicator

Defi nition used in this analysis

Further details Inclusion in MDG or non-MDG index

(Continued from previous page)

Target 3.a: Strengthen the implementation of the World Health Organization Framework Convention on Tobacco Control in all countries, as appropriate

Smoking (3.a.1) Age-standardised prevalence of daily smoking in populations aged 10 years and older, % population aged 10 years and older

We revised this indicator to daily smoking because of data limitations regarding the systematic measurement of current smoking and to refl ect populations aged 10 years and older

Non-MDG

Goal 5: Achieve gender equality and empower all women and girls

Target 5.2: Eliminate all forms of violence against all women and girls in the public and private spheres, including traffi cking and sexual and other types of exploitation

Intimate partner violence (5.2.1)

Age-standardised prevalence of women aged 15 years and older who experienced intimate partner violence, % women aged 15 years and older

Existing datasets do not comprehensively measure the status of ever-partnered women relative to never-partnered women; therefore, the denominator was revised to all women aged 15 years and older. Data on exposure to subtypes of violence are not systematically available across geographies and over time

Non-MDG

Goal 6: Ensure availability and sustainable management of water and sanitation for all

Target 6.1: By 2030, achieve universal and equitable access to safe and aff ordable drinking water for all

Water (6.1.1) Risk-weighted prevalence of populations using unsafe or unimproved water sources, as measured by the SEV for unsafe water, %

Diff erent types of unsafe water sources have diff erent relative risks associated with poor health outcomes; thus, we revised this indicator to SEV for water, which captures the relative risk of diff erent types of unsafe water sources and then combines them into a risk-weighted prevalence on a scale of 0% (no risk in the population) to 100% (the entire population experiences maximum risk associated with unsafe water)

MDG

Target 6.2: By 2030, achieve access to adequate and equitable sanitation and hygiene for all and end open defecation, paying special attention to the needs of women and girls and those in vulnerable situations

Sanitation (6.2.1a) Risk-weighted prevalence of populations using unsafe or unimproved sanitation, as measured by the SEV for unsafe sanitation, %

We separated reporting for indicator 6.2.1 into sanitation (6.2.1a) and hygiene (6.2.1b). We had three mutually exclusive, collectively exhaustive categories for sanitation at the household level: households with piped sanitation (with a sewer connection); households with improved sanitation without a sewer connection (pit latrine, ventilated improved latrine, pit latrine with slab, or composting toilet), as defi ned by the JMP; and households without improved sanitation (fl ush toilet that is not piped to sewer or septic tank, pit latrine without a slab or open pit, bucket, hanging toilet or hanging latrine, shared facilities, or no facilities), as defi ned by the JMP

MDG

Target 6.2 (as above) Hygiene (6.2.1b) Risk-weighted prevalence of populations with unsafe hygiene (no handwashing with soap), as measured by the SEV for unsafe hygiene, %

Safe hygiene practices were defi ned as handwashing with soap and water following toilet use or contact with excreta. We separated reporting for indicator 6.2.1 into sanitation (6.2.1a) and hygiene (6.2.1b)

Non-MDG

Goal 7: Ensure access to aff ordable, reliable, sustainable, and modern energy for all

Target 7.1: By 2030, ensure universal access to aff ordable, reliable, and modern energy services

Household air pollution (7.1.2)

Risk-weighted prevalence of household air pollution, as measured by the SEV for household air pollution, %

Existing datasets do not comprehensively measure population use of clean fuels and technology for heating and lighting across geographies; thus, we revised this indicator to focus on exposure to clean (or unclean) fuels used for cooking

Non-MDG

Goal 8: Promote sustained, inclusive, and sustainable economic growth, full and productive employment, and decent work for all

Target 8.8: Protect labour rights and promote safe and secure working environments for all workers, including migrant workers, in particular women migrants, and those in precarious employment

Occupational risk burden (8.8.1)

Age-standardised all-cause DALY rate attributable to occupational risks, per 100 000 population

We revised this indicator to the DALY rate attributable to occupational risks because DALYs combine measures of mortality and non-fatal outcomes into a singular summary measure, and occupational risks represent the full range of safety hazards that could be encountered in working environment

Non-MDG

(Table 1 continues on next page)

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Three broad approaches can be used to create composite measures: normative, preference weighted, and statistical. Normative approaches combine each indicator based on fi rst principles or an over-riding construct such as the contribution of each indicator to overall health. Preference-weighted approaches weight each indicator by expressed or elicited social preferences for the relative importance of diff erent indicators. Statistical approaches seek to reduce a long set of variables or indicators into common components of variance using methods such as principal component analysis or factor analysis. In this case, because the SDGs refl ect the collective vision of UN member states, we used a preference-weighted approach, assuming that each SDG target should be treated equally.

To combine indicators, we adopted methods used to construct the Human Development Index,43 which include rescaling each indicator on a scale from 0 to 100 and then combining indicators using the geometric mean. The geometric mean allows indicators with very high values to partly compensate for low values on other indicators (referred to as partial substitutability). In the methods appendix pp 312–13, we describe results from alternative index construction methods (ie, principal

component analysis; the arithmetic mean across targets referred to as complete substitutability; and the minimum value across targets referred to as zero substitutability). Quantitative targets for each of the health-related SDG indicators are not universally specifi ed. As a result, we rescaled each health-related SDG indicator on a scale from 0 to 100, with 0 being the lowest (worst) value observed and 100 being the highest (best) value observed over the time period 1990–2015. We log-transformed mortality and morbidity before rescaling. We then estimated the health-related SDG index by fi rst computing the geometric mean of each rescaled health-related SDG indicator for a given target, followed by the geometric mean of resulting values across all SDG targets. To avoid problems with indicator values close to 0, when computing indices we applied a fl oor of one to all indicators. This analytic approach weights each of the health-related SDG targets equally. In addition to the health-related SDG index, we also used the same methods to construct an index that represents 14 health-related SDG indicators that were previously MDG indicators and an index representing 19 non-MDG indicators (table 1). Uncertainty in the indicator and indices values was computed using a simulation analysis.

Health-related SDG indicator

Defi nition used in this analysis

Further details Inclusion in MDG or non-MDG index

(Continued from previous page)

Goal 11: Make cities and human settlements inclusive, safe, resilient, and sustainable

Target 11.5: By 2030, signifi cantly reduce the number of deaths and the number of people aff ected and substantially decrease the direct economic losses relative to global gross domestic product caused by disasters, including water-related disasters, with a focus on protecting the poor and people in vulnerable situations

Disaster (11.5.1; same as Indicators 1.5.1 and 13.1.2)

Age-standardised death rate due to exposure to forces of nature, per 100 000 population

Existing datasets do not comprehensively measure missing people and people aff ected by natural disasters; we revised this indicator to exposure to forces of nature and reported in age-standardised rates

Non-MDG

Target 11.6: By 2030, reduce the adverse per-capita environmental impact of cities, including by paying special attention to air quality and municipal and other waste management

Mean PM2·5 (11.6.2) Population-weighted mean levels of PM2·5, μg/m³

No indicator modifi cations required Non-MDG

Goal 13: Take urgent action to combat climate change and its impacts

Target 13.1: Strengthen resilience and adaptive capacity to climate-related hazards and natural disasters in all countries

Disaster (13.1.2; same as Indicators 1.5.1 and 11.5.1)

Age-standardised death rate due to exposure to forces of nature, per 100 000 population

Existing datasets do not comprehensively measure missing people and people aff ected by natural disasters; we revised this indicator to exposure to forces of nature and reported in age-standardised rates

Non-MDG

Goal 16: Promote peaceful and inclusive societies for sustainable development, provide access to justice for all, and build eff ective, accountable and inclusive institutions at all levels

Target 16.1: Signifi cantly reduce all forms of violence and related death rates everywhere

Violence (16.1.1) Age-standardised death rate due to interpersonal violence, per 100 000 population

Existing datasets do not comprehensively measure displacement and migratory status of victims of intentional homicide; we revised this indicator to deaths due to interpersonal violence (ie, homicide)

Non-MDG

Target 16.1 (as above) War (16.1.2) Age-standardised death rate due to collective violence and legal intervention, per 100 000 population

Existing datasets do not comprehensively measure the displacement status of deaths due to confl ict; we revised this indicator to deaths due to collective violence and legal intervention (ie, war)

Non-MDG

Detailed descriptions of the data sources and methods used to estimate each health-related SDG indicator are in the methods appendix pp 10–311. SDG=Sustainable Development Goal. MDG=Millennium Development Goal. IOTF=International Obesity Task Force. GBD=Global Burden of Disease Study. NCDs=non-communicable diseases. SEV=summary exposure value. WaSH=water, sanitation, and hygiene. JMP=Joint Monitoring Program. DALY=disability-adjusted life-year. PM2·5=fi ne particulate matter smaller than 2·5 μm.

Table 1: Health-related SDG goals and targets proposed by the Inter-Agency and Expert Group on SDG Indicators, and health-related SDG indicators used in this analysis

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Relations between health-related SDG indicators and the Socio-demographic Index and healthy life expectancyAs part of GBD 2015, we assessed cause-specifi c disease burden and risk exposure along the development spectrum, providing context on expected changes as

countries progress to higher levels of income per person, higher educational attainment, and lower fertility.34,37–39 We conducted a similar analysis by examining the relations of the overall health-related SDG index and each of the individual health-related SDG indicators

Health-related SDG indicator Measurement needs and strategy

Goal 3: Ensure healthy lives and promote wellbeing for all at all ages

Target 3.5: Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol

3.5.1: Coverage of treatment interventions (pharmacological, psychosocial and rehabilitation and aftercare services) for substance use disorders

Prevalence of specifi c substance use disorders (opioid use disorders, cocaine use disorders, amphetamine use disorders, and cannabis use disorders), as well as alcohol use disorders, are presently estimated as part of GBD. Systematic reviews on coverage of specifi c interventions (eg, opioid substitution therapy) are in progress by GBD collaborators

Target 3.8: Achieve universal health coverage, including fi nancial risk protection, access to quality essential health-care services and access to safe, eff ective, quality and aff ordable essential medicines and vaccines for all

3.8.2: Number of people covered by health insurance or a public health system per 1000 population

Omission of information on insurance depth and status of user fees within the public health system might limit the applications of this indicator. Construction of proxy measures of health-care use, for both outpatient and hospital care, by country and over time is feasible as part of future iterations of GBD and is likely to be an improved measurement strategy

Target 3.b: Support the research and development of vaccines and medicines for the communicable and non-communicable diseases that primarily aff ect developing countries, provide access to aff ordable essential medicines and vaccines, in accordance with the Doha Declaration on the TRIPS Agreement and Public Health, which affi rms the right of developing countries to use to the full the provisions in TRIPS regarding fl exibilities to protect public health, and, in particular, provide access to medicines for all

3.b.1: Proportion of the population with access to aff ordable medicines and vaccines on a sustainable basis. The recommended measure is percentage of health facilities with essential medicines and life-saving commodities in stock

Across all geographies and over time, comparable data on the stocking and stock-out rates of essential medicines and vaccines for all facility types (hospitals, primary care facilities, pharmacies, and other health-care outlets) and facility ownership (public, private, informal) are not available at present. In the absence of robust measures of stock-outs in both the public and private sectors across countries and over time, the measurement strategy for producing comparable results for this indicator is unclear. Furthermore, the proposed indicator stipulates measurement of not only access to medicines and vaccines, but also access to affordable medicines and vaccines. No comprehensive and comparable datasets on the status of essential medicine and vaccine affordability, in addition to their stocks, presently exist

Target 3.b (as above) 3.b.2: Total net offi cial development assistance to the medical research and basic health sectors

DAH is currently assessed within a comprehensive, comparable analytical framework by source, channel, recipient country, and health focus area from 1990 to 2015; however, funding specifi cally for medical research (eg, research and development of vaccines and medicines, as described in Target 3.b) is not systematically available across source and recipient countries. Additionally, the appropriate assessment of country-level performance remains unclear (eg, whether countries that receive high levels of DAH for medical research are equivalent, in terms of indicator performance, to countries that disperse high levels of DAH for medical research)

Target 3.c: Substantially increase health fi nancing and the recruitment, development, training and retention of the health workforce in developing countries, especially in least developed countries and small island developing States

3.c.1: Health worker density and distribution, as measured by number of health workers per 1000 population by cadre. Cadres include generalist medical practitioners, specialist medical practitioners (surgeons, anaesthetists, obstetricians, emergency medicine specialists, cardiologists, paediatricians, psychiatrists, ophthalmologists, gynaecologists, etc), nursing and midwifery professionals, and traditional and complementary medicine professionals, among others

A systematic analysis of population census data and Labour Force Surveys is possible as part of future iterations of GBD. The total quantity of individual health worker cadres that could be comparably assessed by geography by year will be a function of the availability of detailed International Labour Organization occupational codes across geographies and survey iteration

Target 3.d: Strengthen the capacity of all countries, in particular developing countries, for early warning, risk reduction and management of national and global health risks

3.d.1: International Health Regulations (IHR) capacity and health emergency preparedness. The WHO-recommended measure is the percentage of 13 core capacities that have been attained at a specifi c time (IHR core capacity index). The 13 core capacities are (1) national legislation, policy, and fi nancing; (2) coordination and national focal point communications; (3) surveillance; (4) response; (5) preparedness; (6) risk communication; (7) human resources; (8) laboratory; (9) points of entry; (10) zoonotic events; (11) food safety; (12) chemical events; and (13) radionuclear emergencies

Comprehensive and comparable data for all components of the IHR core capacity index, for all geographies and over time, are not available at present. Specifi c core capacities, such as zoonotic events, could be assessed as part of future iterations of GBD; other core capacities, such as coordination and national focal point communications, have no clear measurement strategy beyond self-report from country representatives or secondary research on policy status and types of surveillance systems available, among others

(Table 2 continues on next page)

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with the Socio-demographic Index (SDI), a summary measure of development that uses lag-distributed income per person, average educational attainment in the population over age 15 years, and the total fertility

rate. The SDI was constructed using the same method for the Human Development Index and the health-related SDG index. Each of the three components was fi rst rescaled on a 0–1 scale, with 0 being the lowest (worst)

Health-related SDG indicator Measurement needs and strategy

(Continued from previous page)

Goal 5: Achieve gender equality and empower all women and girls

Target 5.2: Eliminate all forms of violence against all women and girls in the public and private spheres, including traffi cking and sexual and other types of exploitation

5.2.2: Proportion of women and girls aged 15 years and older subjected to sexual violence by persons other than an intimate partner in the previous 12 months, by age and place of occurrence

Prevalence of intimate partner violence among women and girls aged 15 years and older is currently estimated as part of GBD. An updated systematic review of the literature, data re-extraction, and analysis are needed to specifi cally quantify prevalence of sexual violence (separately or in addition to physical violence, or both) and by persons other than an intimate partner. Data availability by geography by year on the latter, sexual violence by persons other than intimate partners, might be limited

Target 5.6: Ensure universal access to sexual and reproductive health and reproductive rights as agreed in accordance with the Programme of Action of the International Conference on Population and Development and the Beijing Platform for Action and the outcome documents of their review conferences

5.6.1: Proportion of women aged 15–49 years who make their own informed decisions regarding sexual relations, contraceptive use, and reproductive health care

The proportion of women who make their own informed decisions regarding all three dimensions of this indicator—sexual relations, contraceptive use, and reproductive health care—are included in the Demographic and Health Survey (DHS) series. Data availablility for non-DHS countries is unclear. The feasibility of measuring this indicator as part of future iterations of GBD is under review at present

Target 5.6 (as above) 5.6.2: Number of countries with laws and regulations that guarantee women aged 15–49 access to sexual and reproductive health care, information, and education

Across all geographies and over time, comprehensive and comparable data documenting the status of laws and regulations regarding access to sexual and reproductive health care, information, and education do not exist at present. Compiling the past and current status of such laws and regulations might be possible; however, systematic assessment of their depth or intensity, enforcement, and eff ectiveness in guaranteeing access to reproductive health care, information, and education might be challenging across countries and over time

Goal 6: Ensure availability and sustainable management of water and sanitation for all

Target 6.3: By 2030, improve water quality by reducing pollution, eliminating dumping and minimising release of hazardous chemicals and materials, halving the proportion of untreated waste water, and substantially increasing recycling and safe reuse globally

6.3.1: Proportion of waste water safely treated. UN Water defi nes this indicator as the proportion of waste water generated by both households (sewage and faecal sludge), as well as economic activities (based on ISIC categories) safely treated compared to total waste water generated both through households and economic activities. While the defi nition conceptually includes waste water generated from all economic activities, monitoring will focus on waste water generated from hazardous industries (as defi ned by relevant ISIC categories)

Across all geographies and over time, comprehensive and comparable data containing information on total waste water, as generated by both households and non-household entities (however they are to be defi ned), and waste water treatment status do not exist at present. UN Water suggests there will be suffi cient data to generate estimates of global and regional levels of safely treated waste water by 2018; however, in the absence of more country-level data, it is diffi cult to determine the representativeness of such global and regional estimates

Goal 16: Promote peaceful and inclusive societies for sustainable development, provide access to justice for all and build eff ective, accountable, and inclusive institutions at all levels

Target 16.1: Signifi cantly reduce all forms of violence and related death rates everywhere

16.1.3: Proportion of population subjected to physical, psychological, or sexual violence in the previous 12 months

Prevalence of intimate partner violence among women and girls aged 15 years and older is currently estimated as part of GBD, as are the incidence and prevalence of interpersonal violence among all populations. An expanded systematic review of the literature and available data sources for all types of violence (physical, psychological, and sexual) for both men and women of all ages would be required for inclusion in future iterations of GBD

Target 16.1 (as above) 16.1.4: Proportion of people that feel safe walking alone around the area they live

Comprehensive data on reported safety, in general or walking alone near one’s residence (or both), do not currently exist across geographies or over time. Substantive primary data collection is likely to be required

Target 16.2: End abuse, exploitations, traffi cking and all forms of violence against and torture of children

16.2.3: Proportion of young women and men aged 18–29 years who experienced sexual violence by age 18

Prevalence of intimate partner violence among women and girls aged 15 years and older is estimated as part of GBD. An expanded systematic review and analysis of the literature and available data sources for both men and women, and for all types of sexual violence (ie, not limited to intimate partners) would be required. The feasibility of measuring this indicator as part of future iterations of GBD is under review at present

(Table 2 continues on next page)

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value observed in the time period 1980–2015 and 1 being the highest (best) value observed. SDI was then computed as the geometric mean of these three rescaled components. To capture average relations, we used a spline regression (ie, piecewise linear regression with so-called knots specifying the intersection between pieces) of the health-related SDG indicators and health-related SDG index on SDI using the full set of data by country from 1990 to 2015. We also compared the health-related SDG indicators with the GBD 2015 estimates of healthy life expectancy38 to explore the relation between the SDGs and overall health achievement for each country.

Role of the funding sourceThe funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. The corresponding author had full access to all the data in the study and had fi nal responsibility for the decision to submit for publication.

ResultsOf the 33 health-related SDG indicators, 21 were associated with a defi ned target, with 18 of them having an absolute level and three having a target relative to 2015 levels (table 3). The proportion of countries already meeting targets linked to health-related SDG indicators in 2015, as specifi ed by absolute levels to be achieved, ranged from more than 60% for two indicators (maternal mortality ratio and under-5 mortality) to 0% for nine indicators. For these nine indicators, all targets involved full elimination of diseases (eg, tuberculosis, HIV, and neglected tropical diseases), reducing prevalence of health outcomes or risk to 0% (eg, childhood overweight and intimate partner violence), or reaching 100% for intervention coverage or health service provision (eg, skilled birth attendance, met need with modern contraception, and UHC tracer interventions).

In 2015, the median health-related SDG index was 59∙3 (95% uncertainty interval [UI] 56∙8–61∙8) across all 188 countries. This index was highest in Iceland (85∙5, 84∙2–86∙5), Singapore (85∙3, 84∙1–86∙3), and Sweden (85∙3, 84∙2–86∙2) and lowest in the Central African Republic (20∙4, 15∙9–24∙9), Somalia (21∙6, 16∙0–25∙9), and South Sudan (22∙5, 15∙5–26∙6; fi gure 1). Diff erences in the 95% UI range stem largely from diff erences in the availability and quality of underlying data sources for estimating individual indicators; for example, data were sparser for Somalia than they were for Sweden. Some patterns emerged contrary to what might have been expected. For example, the USA (74∙9, 73∙6–75∙9) ranked 28th, driven by poorer performance on MDG indicators (eg, maternal mortality ratio) than other high-income countries44 and worse performance on non-MDG indicators—most notably, alcohol consumption, childhood overweight, and mortality due to interpersonal violence, self-harm, and unintentional poisoning. India (41∙7, 39∙7–43∙7), despite rapid economic growth, was ranked 143rd, just below Comoros and Ghana.

Levels of the health-related SDG index were highly clustered (fi gure 2), with countries in the highest quintile (≥71·5) located mainly in western Europe, high-income North America, parts of Asia (Japan, South Korea, Singapore, and Brunei), and Australasia. The second highest quintile (62·5–71·5) included countries in southern Latin America, parts of eastern Europe, most of the Caribbean, and a subset of countries across other regions (eg, Mexico, Jordan, Azerbaijan, Malaysia, and Costa Rica), whereas countries in the middle quintile (55·7–62·5) were primarily located in South America; parts of east, central, and southeast Asia; and parts of North Africa and the Middle East. The countries in the fourth quintile (37·8–55·7) were mainly found in south and southeast Asia, southern sub-Saharan Africa, parts of

Health-related SDG indicator Measurement needs and strategy

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Goal 17: Strengthen the means of implementation and revitalise the global partnership for sustainable development

Target 17.19: By 2030, build on existing initiatives to develop measurements of progress on sustainable development that complement gross domestic product, and support statistical capacity building in developing countries

17.19.2: Proportion of countries that (a) have conducted at least one population and housing census in the last 10 years; and (b) have achieved 100% birth registration and 80% death registration

For Indicator 17.19.2(a), a comprehensive assessment of the availability and timing of population and housing censuses across all geographies is possible as part of GBD. For Indicator 17.19.2(b), the systematic collation of vital registration data for all geographies is required; at present, vital registration data reported to WHO do not fully cover all geographies or years under analysis. Such data collation eff orts would be required for both birth and death registration individually to determine completeness, with the latter viewed as more immediately feasible for future iterations of GBD

SDG=Sustainable Development Goal. GBD=Global Burden of Disease. TRIPS=Agreement on Trade-Related Aspects of Intellectual Property Rights. DAH=development assistance for health. IHR=International Health Regulations. DHS=Demographic and Health Survey. ISIC=International Standard Industrial Classifi cation.

Table 2: Health-related SDG indicators (proposed by the Inter-Agency and Expert Group on SDG Indicators) excluded in the present analysis, and measurement needs and strategy for future reporting, by SDG target

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Median (IQR) Minimum Maximum SDG target by 2030*

Proportion of 188 countries achieving the SDG target in 2015

Disaster (Indicator 1.5.1; same as Indicators 11.5.1 and 13.2.1)—age-standardised death rate due to exposure to forces of nature, per 100 000 population

0·0 (0·0–0·1) 0·0 7·5 Undefi ned NA

Stunting (Indicator 2.2.1)—prevalence of stunting in children under age 5 years, % 12·5% (4·6–26·5) 0·0% 54·5% Eliminate 16·5%

Wasting (Indicator 2.2.2a)—prevalence of wasting in children under age 5 years, % 3·6% (1·8–7·1) 0·0% 21·7% Eliminate 16·5%

Overweight (Indicator 2.2.2b)—prevalence of overweight in children aged 2–4 years, % 23·1% (14·1–32·1) 2·6% 54·5% Eliminate 0·0%

Maternal mortality ratio (Indicator 3.1.1)—maternal deaths per 100 000 livebirths 49·1 (15·2–239·1) 0·7 1073·9 <70 deaths per 100 000 livebirths

61·2%

Skilled birth attendance (Indicator 3.1.2)—proportion of births attended by skilled health personnel (doctors, nurses, midwives, or country-specifi c medical staff [eg, clinical offi cers]), %

98·1% (80·9–99·2) 20·6% 99·6% 100% 0·0%

Under-5 mortality (Indicator 3.2.1)—probability of dying before age 5 years per 1000 livebirths 17·5 (7·1–44·9) 1·9 130·5 At least as low as 25 deaths per 1000 livebirths

60·1%

Neonatal mortality (Indicator 3.2.2)—probability of dying during the fi rst 28 days of life per 1000 livebirths

9·3 (3·5–21·0) 1·0 40·6 At least as low as 12 deaths per 1000 livebirths

57·5%

HIV (Indicator 3.3.1)—age-standardised rate of new HIV infections, per 1000 population 0·1 (0·0–0·4) 0·0 27·4 Eliminate 0·0%

Tuberculosis (Indicator 3.3.2)—age-standardised rate of new and relapsed tuberculosis cases, per 1000 population

0·6 (0·2–1·5) 0·0 26·1 Eliminate 0·0%

Malaria (Indicator 3.3.3)—age-standardised rate of malaria cases, per 1000 population 0·0 (0·0–18·5) 0·0 286·8 Eliminate 52·1%

Hepatitis B (Indicator 3.3.4)—age-standardised rate of hepatitis B incidence, per 100 000 population

18 38·6 (1070·4–2098·4) 444·5 2554·1 Undefi ned NA

Neglected tropical diseases (Indicator 3.3.5)—age-standardised prevalence of neglected tropical diseases, per 100 000 population

14 474·0 (236·3–46 139·0) 9·8 119 695·4 Eliminate 0·0%

Non-communicable diseases (Indicator 3.4.1)—age-standardised death rate due to cardiovascular disease, cancer, diabetes, and chronic respiratory disease in populations aged 30–70 years, per 100 000 population

422·0 (291·4–552·5) 154·0 1442·5 Reduce by one-third

NA

Suicide (Indicator 3.4.2)—age-standardised death rate due to self-harm, per 100 000 population

10·3 (6·9–14·3) 2·2 34·0 Reduce by one-third

NA

Alcohol (Indicator 3.5.2)—risk-weighted prevalence of alcohol consumption, as measured by the SEV for alcohol use, %

7·8% (4·2–11·1) 0·7% 28·7% Undefi ned NA

Road injuries (Indicator 3.6.1)—age-standardised death rate due to road injuries, per 100 000 population

15·3 (9·7–23·2) 3·0 63·9 Reduce by half† NA

Family planning need met, modern contraception (Indicator 3.7.1)—proportion of women of reproductive age (15–49 years) who have their need for family planning satisfi ed with modern methods, % women aged 15–49 years

72·4% (46·6–87·0) 15·8% 99·1% 100% 0·0%

Adolescent birth rate (Indicator 3.7.2)—birth rates for women aged 10–14 years and women aged 15–19 years, number of livebirths per 1000 women aged 10–14 years and women aged 15–19 years

22·9 (9·4–37·8) 1·1 102·6 Undefi ned NA

Universal health coverage tracer (Indicator 3.8.1)—coverage of universal health coverage tracer interventions for prevention and treatment services, %

79·2% (64·9–88·1) 23·3% 94·6% 100% 0·0%

Air pollution mortality (Indicator 3.9.1)—age-standardised death rate attributable to household air pollution and ambient air pollution, per 100 000 population

74·9 (40·6–170·7) 9·0 427·3 Undefi ned NA

WaSH mortality (Indicator 3.9.2)—age-standardised death rate attributable to unsafe WaSH, per 100 000 population

8·4 (2·4–44·2) 0·7 318·0 Undefi ned NA

Poisons (Indicator 3.9.3)—age-standardised death rate due to unintentional poisonings, per 100 000 population

0·8 (0·4–2·0) 0·1 7·1 Undefi ned NA

Smoking (Indicator 3.a.1)—age-standardised prevalence of daily smoking in populations aged 10 years and older, % population aged 10 years and older

11·0% (6·5–16·3) 0·7% 29·5% Undefi ned NA

Intimate partner violence (Indicator 5.2.1)—age-standardised prevalence of women aged 15 years and older who experienced intimate partner violence, % women aged 15 years and older

19·0% (13·7–25·7) 4·7% 44·6% Eliminate 0·0%

Water (Indicator 6.1.1)—risk-weighted prevalence of populations using unsafe or unimproved water sources, as measured by the SEV for unsafe water, %

62·7% (21·2–83·0) 0·0% 98·4% Eliminate 16·0%

Sanitation (Indicator 6.2.1a)—risk-weighted prevalence of populations using unsafe or unimproved sanitation, as measured by the SEV for unsafe sanitation, %

20·6% (3·6–57·5) 0·0% 96·4% Eliminate 16·0%

Hygiene (Indicator 6.2.1b)—risk-weighted prevalence of populations with unsafe hygiene (no handwashing with soap), as measured by the SEV for unsafe hygiene, %

74·2% (60·5–94·1) 36·0% 99·7% Eliminate 0·0%

(Table 3 continues on next page)

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North Africa and the Middle East, and parts of eastern Europe. Countries in western, eastern, and central sub-Saharan Africa, as well as a subset of other countries (eg, Afghanistan, Papua New Guinea, Yemen, and Nepal), dominated the lowest quintile (<37·8) of the health-related SDG index. Although the MDG index was correlated with the non-MDG index, country-level performance on these two indices varied considerably (fi gure 3). Performing well on the health-related MDG index did not guarantee good performance on the health-related non-MDG index. For example, the health-related MDG index in 2015 was similar for Indonesia (52∙3, 49∙8–54∙6) and South Africa (48∙9, 46∙0–51∙3), but Indonesia had a much higher non-MDG index (64∙1, 62∙0–66∙6) than that of South Africa (42∙9, 40∙3–45∙5). This diff erence for the non-MDG index was primarily driven by South Africa’s lower performance for indicators such as childhood overweight, harmful alcohol use, and mortality due to self-harm and interpersonal violence.

SDI was highly predictive of the overall health-related SDG index (r²=0∙88) and MDG index (r²=0∙92; fi gure 4). The non-MDG index was less well predicted by SDI (r²=0∙79). This fi nding is refl ective of the variable relations between individual health-related SDG indicators and SDI (results appendix pp 346–47). For instance, SDI was a poor predictor of mortality due to exposure to forces of nature, self-harm, interpersonal violence, and war (collective violence and legal intervention), as well as childhood overweight, intimate partner violence, and ambient particulate matter pollution. By contrast, SDI was highly predictive of maternal mortality ratio, under-5 mortality, and neonatal mortality, as well as mortality attributable to unsafe water, sanitation, and hygiene. Notably, the overall health-related SDG index also had a strong relation with healthy life expectancy (r²=0∙86), a summary measure of population health.

By subtracting expected levels for the health-related SDG index, on the basis of SDI alone, from observed levels (fi gure 5), we could identify potential geographical deviations well above or below expected values on the health-related SDG index. Countries that represent substantial deviations from the average might warrant further investigation to understand how and why they are underperforming or overperforming relative to the average. This deviation might be due, for example, to more or less effi cient use of resources to improve health. Many countries in western Europe, Latin America, and parts of east and southeast Asia, as well as other countries such as Australia, recorded health-related SDG index levels that were higher than expected on the basis of SDI alone. Many of the countries with a health-related SDG index below expected levels on the basis of SDI were located in southern and central sub-Saharan Africa, eastern Europe and central Asia (eg, Belarus and Ukraine), North Africa and the Middle East, south Asia, and selected countries such as the USA.

To provide a preliminary indication of potential trajectories in the next 15 years, we assessed absolute changes in the past 15 years for each of the 33 health-related SDG indicators and three summary indices (overall health-related SDG index, health-related MDG index, and non-MDG index). Overall, health-related SDG indicators largely improved since 2000, as summarised by the health-related SDG index; notably, gains in the health-related MDG index generally exceeded improvements in the non-MDG index (fi gure 6). Across countries, the most pronounced progress occurred for UHC tracer interventions, met need with modern contraception, hygiene, under-5 mortality, and neonatal mortality. Such striking gains for the indicator on UHC tracer interventions refl ected the scale-up of antiretroviral therapy and coverage of insecticide-treated nets in malaria-endemic countries since the early 2000s.31,44,45 Of note, the relatively small

Median (IQR) Minimum Maximum SDG target by 2030*

Proportion of 188 countries achieving the SDG target in 2015

(Continued from previous page)

Household air pollution (Indicator 7.1.2)—risk-weighted prevalence of household air pollution, as measured by the SEV for household air pollution, %

7·1% (0·3–36·0) 0·0% 73·6% Eliminate 16·5%

Occupational risk burden (Indicator 8.8.1)—age-standardised all-cause DALY rate attributable to occupational risks, per 100 000 population

757·7 (552·7–999·2) 278·7 2148·3 Undefi ned NA

Mean PM2·5 (Indicator 11.6.2)—population-weighted mean levels of PM2·5, μg/m³ 21·7 (15·1–37·6) 3·4 107·3 Undefi ned NA

Violence (Indicator 16.1.1)—age-standardised death rate due to interpersonal violence, per 100 000 population

3·7 (1·6–8·2) 0·4 58·3 Undefi ned NA

War (Indicator 16.1.2)—age-standardised death rate due to collective violence and legal intervention, per 100 000 population

0·0 (0·0–0·0) 0·0 309·9 Undefi ned NA

SDG=Sustainable Development Goal. NA=not applicable. SEV=summary exposure value. WaSH=water, sanitation, and hygiene. DALY=disability-adjusted life-year. PM2·5=fi ne particulate matter smaller than 2·5 μm in diameter. *SDG targets without explicit achievement thresholds, such as “signifi cantly reduce by 2030”, or with reduction-based thresholds, such as “reduce by one-third”, are reported as undefi ned. †The target year for achieving indicator 3.6.1 is 2020.

Table 3: Performance of health-related SDG indicators across all countries, 2015

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74

76

81

70

89

79

78

100

99

100

99

100

100

100

99

99

99

99

100

99

99

99

99

100

99

99

100

100

99

99

100

100

100

99

100

99

100

99

100

100

99

100

95

66

78

89

82

90

79

93

90

94

90

87

92

72

91

86

88

83

89

89

79

89

94

94

87

83

87

92

96

84

100

94

97

99

96

65

83

90

86

94

80

97

89

94

93

90

94

78

90

87

89

83

89

91

76

90

97

95

88

83

87

93

95

85

99

94

98

99

69

36

54

53

61

41

46

70

64

74

57

55

37

54

54

56

57

62

56

57

54

57

56

64

60

54

60

49

69

51

52

65

54

57

81

63

60

82

85

56

99

74

84

75

80

82

65

49

87

84

81

85

85

86

73

80

77

81

87

93

86

78

84

74

70

82

56

69

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

66

76

18

81

63

49

85

61

77

66

83

81

81

56

82

82

83

82

83

85

81

81

81

81

69

71

83

86

81

85

81

85

62

81

100

100

86

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

65

63

72

80

81

63

69

90

75

79

79

86

79

61

85

92

77

83

78

77

84

82

84

86

88

82

80

86

82

78

99

87

85

91

50

97

47

49

53

46

49

36

87

44

41

65

57

79

71

50

41

87

55

55

82

56

59

57

55

54

57

69

43

64

66

51

59

60

46

68

71

38

56

40

54

64

53

50

53

87

54

70

68

51

47

57

39

54

62

49

53

64

54

56

55

57

48

57

42

57

87

62

79

79

58

83

76

83

64

91

67

80

78

77

72

61

75

93

73

70

88

88

100

92

85

95

79

79

90

86

89

94

94

94

93

96

79

95

89

92

95

79

100

79

74

71

94

95

88

89

86

95

95

93

90

92

82

95

94

95

97

96

92

91

97

95

95

91

87

95

82

53

91

84

66

79

68

90

86

89

80

73

83

67

87

92

81

92

89

86

75

81

85

84

76

81

90

86

83

73

73

84

92

84

96

95

82

93

95

93

98

96

94

95

96

97

96

96

97

97

97

96

95

96

87

96

91

97

96

96

97

97

98

100

96

99

97

89

71

79

76

83

99

77

86

89

80

78

91

84

88

96

83

90

82

84

84

83

83

86

86

90

99

94

83

91

92

83

93

96

77

94

77

60

71

99

95

95

84

75

94

80

83

82

73

76

96

92

78

92

80

84

81

80

87

81

95

88

80

87

100

77

89

87

62

86

76

66

72

80

81

66

57

77

83

80

71

84

82

79

81

89

76

84

73

94

88

77

85

63

74

71

89

83

73

75

84

71

100

71

42

94

74

37

63

47

69

57

23

50

44

57

55

72

52

54

55

39

60

46

54

49

49

65

66

69

58

47

59

55

48

75

72

66

60

73

96

93

67

84

70

68

83

92

87

62

82

67

66

96

78

92

66

70

90

83

77

83

78

74

83

91

71

80

83

80

67

100

86

46

72

100

100

90

100

100

100

87

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

99

86

95

100

100

92

100

100

100

97

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

58

55

66

82

96

66

95

97

85

55

82

97

68

92

86

87

89

92

93

89

70

90

85

98

97

100

88

77

94

93

95

95

88

90

99

98

100

100

100

94

100

100

100

95

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

68

63

61

68

71

71

80

96

72

68

81

79

58

92

72

64

82

63

71

71

70

65

91

73

76

74

70

73

77

74

76

81

98

69

51

63

42

57

84

72

74

63

63

53

65

52

71

86

53

64

59

55

68

62

59

71

58

72

82

78

61

71

77

65

70

81

55

76

74

41

67

83

71

48

42

87

75

81

77

57

67

69

77

82

69

68

77

81

74

82

77

81

72

69

74

82

66

86

87

74

97

83

100

100

100

100

100

100

100

100

100

100

22

20

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

90

72

83

92

90

85

88

92

91

89

92

91

89

85

92

92

92

92

92

92

87

92

91

94

92

91

92

92

94

90

92

94

92

93

66

75

67

66

68

68

70

70

68

68

70

70

70

75

70

72

73

73

73

73

74

75

75

74

76

75

76

74

76

78

77

80

81

791 Iceland

2 Singapore

3 Sweden

4 Andorra

5 UK

6 Finland

7 Spain

8 Netherlands

9 Canada

10 Australia

11 Norway

12 Luxembourg

13 Ireland

14 Malta

15 Germany

16 Denmark

17 Cyprus

18 Belgium

19 Switzerland

20 Italy

21 Brunei

22 Portugal

23 Israel

24 France

25 Slovenia

26 Greece

27 Japan

28 USA

29 Estonia

30 New Zealand

31 Austria

32 Taiwan(province of China)

33 Antigua andBarbuda

34 Czech Republic

SDG index

Disaste

r

Stunting

Wasting

Overweight

MMRSBA

NN mort HIV

Tuberculosis

Malaria

Hepatitis B NTDs

NCDs

Suicide

Alcohol

Road injurie

s

FP need met, m

od

Adol birt

h rate

UHC tracer

Air poll m

ort

WaSH mort

Poisons

Smoking IPVWater

Sanitatio

n

Hygiene

HH air poll

Occ ris

k burden

Mean PM2·5

Violence War

MDG index

Non-MDG in

dex

100755025

Value

(Figure 1 continues on next page)

Articles

14 www.thelancet.com Published online September 21, 2016 http://dx.doi.org/10.1016/S0140-6736(16)31467-2

100755025

Value

SDG index

Disaste

r

Stunting

Wasting

Overweight

MMRSBA

Under-5 m

ort

NN mort HIV

Tuberculosis

Malaria

Hepatitis B NTDs

NCDs

Suicide

Alcohol

Road injurie

s

FP need met, m

od

Adol birt

h rate

UHC tracer

Air poll m

ort

WaSH mort

Poisons

Smoking IPVWater

Sanitatio

n

Hygiene

HH air poll

Occ ris

k burden

Mean PM2·5

Violence War

MDG index

Non-MDG in

dex

64

64

65

65

65

65

65

66

66

66

66

67

67

67

67

67

67

67

67

68

68

68

69

69

69

69

70

71

71

72

72

73

73

73

100

54

31

40

35

100

100

100

100

100

100

45

100

100

33

100

56

100

100

100

36

100

100

100

100

100

100

100

100

100

100

60

100

56

95

91

89

91

74

74

89

94

80

92

92

93

95

78

97

69

90

88

97

92

90

92

82

92

88

94

91

90

95

94

87

93

97

100

93

85

92

87

98

65

84

93

83

89

92

96

87

84

98

77

96

90

88

92

68

91

68

92

90

91

88

82

92

90

94

89

88

100

23

39

49

65

69

81

22

57

47

59

51

42

81

55

27

31

29

44

92

69

57

59

53

55

82

60

46

57

80

50

39

62

47

54

75

61

52

68

50

52

58

72

61

49

52

58

49

57

60

70

49

77

47

53

49

69

47

66

58

49

71

53

55

80

60

75

69

67

99

99

100

99

92

99

99

99

99

99

99

100

100

100

99

99

99

99

99

99

100

100

100

100

100

99

99

99

98

99

99

99

99

99

74

73

79

75

61

66

78

71

44

59

55

71

58

53

75

67

66

82

60

52

64

86

78

82

63

62

85

62

69

85

71

79

83

90

75

76

81

76

64

69

78

70

41

56

50

72

51

51

77

81

66

83

58

46

63

91

82

85

63

54

84

56

72

84

73

82

82

95

75

59

43

57

43

72

52

73

37

35

30

45

35

58

41

72

33

71

39

37

41

51

40

42

74

34

69

36

41

61

40

78

66

60

64

63

79

70

47

58

66

68

46

81

56

73

62

50

62

75

59

74

57

59

59

47

46

54

83

63

69

67

57

68

68

77

75

50

100

100

100

100

43

100

100

100

100

100

100

95

100

100

100

100

100

100

100

100

100

100

57

100

100

100

100

100

100

100

100

100

100

80

31

63

76

66

69

32

30

66

41

76

76

72

76

43

74

66

74

66

76

76

32

49

57

49

43

76

66

76

32

78

74

66

66

46

100

100

84

100

84

100

100

100

98

64

85

80

98

100

86

100

91

100

77

100

99

100

60

100

86

100

100

100

70

100

100

100

100

99

80

47

64

54

91

91

74

55

41

58

46

87

47

44

79

64

61

55

58

54

53

53

59

50

71

55

62

60

56

58

60

60

52

85

91

53

47

44

86

49

69

64

60

86

61

64

46

55

51

74

52

53

67

75

59

20

59

36

88

86

47

77

61

39

39

55

40

25

98

55

73

59

68

88

89

59

80

76

72

73

65

78

59

71

58

64

61

68

80

42

94

50

95

64

54

68

77

54

62

51

52

62

58

72

73

69

59

76

62

76

71

71

67

59

55

61

63

78

59

71

63

58

66

64

44

70

59

57

72

67

59

68

57

77

80

62

77

59

93

37

75

46

65

17

62

88

89

91

76

84

87

10

86

31

88

90

66

70

62

76

64

94

34

91

85

41

80

79

78

94

73

60

52

70

50

73

70

71

66

45

50

48

60

59

52

63

45

75

49

61

63

83

76

79

62

62

80

56

47

78

48

73

75

100

83

81

94

84

80

79

85

80

85

93

90

94

93

93

94

77

97

82

93

93

83

90

89

90

86

97

84

93

92

91

94

96

97

95

67

58

72

58

64

72

69

56

52

72

70

81

74

48

79

64

75

56

75

76

74

66

67

65

72

79

68

81

76

67

81

69

66

80

67

81

61

88

51

62

72

89

61

66

55

71

64

69

72

81

62

94

59

56

64

88

51

90

71

63

88

61

54

79

67

74

90

83

86

67

78

73

62

58

79

73

59

66

69

75

71

52

80

77

62

64

74

51

93

59

60

56

64

69

84

75

68

80

67

75

82

68

63

23

64

43

82

56

77

28

85

78

86

83

68

81

39

64

58

28

82

92

64

45

60

36

55

87

32

91

67

45

55

52

40

49

50

84

73

82

84

73

50

83

80

59

73

64

73

80

71

87

84

83

73

73

73

82

73

76

65

73

91

73

73

89

84

83

90

67

37

80

39

74

71

21

32

79

48

42

40

32

47

81

94

68

89

79

43

40

74

86

72

89

44

49

81

48

71

83

95

84

85

100

98

95

82

85

74

80

97

93

81

78

77

96

90

54

95

97

92

95

71

76

94

87

97

88

100

92

97

86

90

97

97

98

93

100

55

48

42

43

43

32

41

41

71

38

43

58

53

59

82

38

78

46

39

43

51

66

60

66

40

53

43

48

59

56

67

53

51

92

100

95

98

78

79

95

100

82

100

92

96

97

100

89

98

86

99

74

95

95

98

96

100

96

100

99

94

100

99

94

100

98

95

100

74

66

52

60

54

71

63

69

52

54

61

62

73

48

70

47

47

67

58

57

72

61

57

68

79

58

63

67

65

64

58

74

74

90

21

44

56

51

44

44

26

35

41

57

62

53

62

35

52

56

63

49

62

63

60

54

59

52

36

63

51

61

65

48

67

52

49

44

80

60

42

55

53

52

60

59

45

18

20

36

19

53

48

62

42

48

25

29

57

41

48

41

51

20

72

30

39

65

44

60

69

64

14

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

75

78

72

76

67

61

71

74

65

68

66

71

69

70

82

68

77

79

67

67

73

82

73

82

74

72

80

71

76

82

80

87

86

90

56

57

60

60

63

67

59

62

66

64

66

64

67

64

59

65

61

61

68

68

64

62

66

63

68

68

64

71

68

66

66

66

66

6535 South Korea

36 Hungary

37 Slovakia

38 Uruguay

39 Poland

40 Seychelles

41 Barbados

42 Croatia

43 The Bahamas

44 Jordan

45 Latvia

46 Malaysia

47 Lithuania

48 Mauritius

49 Dominica

50 Saint Lucia

51 Montenegro

52 Argentina

53 Albania

54 Chile

55 Uzbekistan

56 Trinidad andTobago

57 Costa Rica

58 Saint Vincent andthe Grenadines

59 Jamaica

60 Turkmenistan

61 Macedonia

62 Bahrain

63 Maldives

64 Peru

65 Serbia

66 Cuba

67 Bulgaria

68 Kuwait

(Figure 1 continues on next page)

Articles

www.thelancet.com Published online September 21, 2016 http://dx.doi.org/10.1016/S0140-6736(16)31467-2 15

100755025

Value

SDG index

Disaste

r

Stunting

Wasting

Overweight

MMRSBA

Under-5 m

ort

NN mort HIV

Tuberculosis

Malaria

Hepatitis B NTDs

NCDs

Suicide

Alcohol

Road injurie

s

FP need met, m

od

Adol birt

h rate

UHC tracer

Air poll m

ort

WaSH mort

Poisons

Smoking IPVWater

Sanitatio

n

Hygiene

HH air poll

Occ ris

k burden

Mean PM2·5

Violence War

MDG index

Non-MDG in

dex

58

59

59

59

59

59

59

59

59

60

60

60

60

61

61

61

61

62

62

62

62

62

62

62

62

62

62

63

63

63

63

63

63

64

31

52

31

42

32

100

100

30

44

41

39

100

33

100

29

100

50

100

100

100

100

100

46

23

100

100

100

100

50

39

33

34

27

41

75

78

76

62

82

84

75

90

69

86

87

62

90

93

83

90

80

85

77

98

90

88

92

81

85

84

87

79

88

89

92

72

92

81

95

90

96

71

96

87

90

89

80

78

91

72

92

89

96

85

87

87

65

95

93

88

91

63

89

84

95

84

89

89

96

93

91

94

79

57

73

80

70

43

74

51

86

55

62

87

50

32

89

82

45

52

68

16

77

67

67

81

59

55

79

44

52

48

76

71

71

66

53

46

45

58

40

40

55

41

64

64

62

33

46

58

48

49

58

57

62

37

48

43

65

55

46

64

63

61

61

67

45

49

54

50

100

94

97

94

92

95

98

99

95

99

97

90

99

100

97

98

100

100

100

99

100

99

99

100

98

100

99

95

99

99

94

98

100

98

68

54

62

47

59

59

61

49

64

71

66

54

60

73

62

48

63

60

82

60

53

68

69

74

60

74

60

49

73

81

59

59

62

62

72

52

63

47

57

63

59

53

66

74

69

52

59

74

65

42

63

60

83

63

47

73

71

75

60

75

58

46

79

83

62

66

60

62

39

57

39

50

35

45

28

44

37

53

46

30

36

73

40

31

52

42

53

44

32

41

40

61

39

56

58

50

52

74

29

36

37

41

69

54

66

52

56

54

52

59

46

69

45

27

58

62

63

62

60

37

68

61

50

53

48

53

62

73

68

45

46

64

52

51

68

66

94

96

37

100

69

100

60

100

28

100

94

18

37

100

32

33

100

100

100

100

36

100

100

100

40

100

100

100

100

100

51

71

100

77

72

32

74

41

62

17

76

26

33

30

40

36

62

29

70

76

41

41

29

17

76

17

49

40

72

32

31

41

66

66

72

70

76

97

92

90

93

95

88

63

96

63

84

100

89

84

87

100

74

94

100

88

100

93

98

75

100

90

71

100

95

98

100

100

93

71

84

88

75

68

79

52

58

28

51

24

60

67

58

47

61

82

81

55

50

38

53

43

66

32

51

71

65

67

52

48

51

64

82

72

44

72

56

91

63

75

68

44

64

47

60

84

59

88

68

75

69

29

65

22

81

65

67

43

46

25

57

90

91

80

53

75

70

62

67

69

81

95

81

86

67

90

71

85

77

95

74

95

71

91

71

73

79

58

85

91

71

90

29

87

74

88

95

69

49

74

72

82

64

74

42

41

61

78

41

55

49

61

45

25

49

50

43

36

58

49

69

51

27

60

44

59

70

59

45

76

61

76

68

89

55

40

59

53

82

68

90

48

85

79

69

86

80

48

86

89

93

67

89

74

37

76

59

84

85

83

72

69

88

68

56

25

41

24

92

80

87

87

44

73

36

49

46

42

42

49

54

77

69

49

43

71

50

51

63

58

59

69

32

60

66

75

38

76

42

42

60

83

39

39

61

44

92

90

71

78

87

74

91

82

68

88

81

52

81

86

77

75

85

92

85

87

84

81

82

87

77

88

74

79

88

81

69

88

92

88

66

70

65

42

61

60

61

66

56

63

48

58

72

68

72

69

62

54

56

69

68

59

60

59

71

71

64

54

60

58

78

79

70

72

56

57

62

50

56

47

51

42

57

57

75

32

56

80

67

54

80

78

60

51

58

50

79

60

58

82

64

67

76

93

58

56

54

61

78

57

69

47

76

52

59

63

58

91

50

69

83

82

83

63

61

38

69

44

74

55

53

77

73

73

82

62

66

55

65

63

59

68

86

77

80

77

77

68

83

75

58

84

52

39

76

78

77

59

51

53

79

42

85

68

56

78

69

45

61

51

46

31

93

89

86

78

76

50

74

71

89

54

89

54

64

50

96

73

93

50

53

73

80

87

50

61

72

54

68

81

70

50

39

78

57

83

70

60

73

64

37

22

31

63

39

33

16

41

58

22

50

49

40

34

41

33

26

61

34

35

31

35

57

51

44

22

21

64

70

77

45

67

43

44

70

84

53

38

69

79

77

89

68

95

66

72

89

98

92

86

80

70

99

82

74

83

56

69

92

97

91

73

80

91

77

86

78

90

44

23

41

46

36

34

29

45

39

31

38

44

36

51

57

32

63

73

54

42

35

41

49

53

63

40

27

67

46

35

67

42

44

59

89

100

68

76

76

90

89

90

79

99

79

82

94

100

91

94

98

92

100

80

94

84

95

61

100

100

99

93

89

61

92

97

98

92

62

78

54

42

45

44

51

57

45

73

43

51

47

53

54

67

43

38

43

42

49

38

69

64

53

71

69

39

49

70

58

58

56

57

37

38

45

29

60

71

45

76

44

27

25

59

67

8

56

56

47

53

22

91

53

77

52

44

49

40

52

42

53

30

63

64

61

53

3

79

32

54

26

43

18

41

63

75

69

75

15

77

12

32

45

28

76

57

26

42

45

45

8

68

42

50

61

57

23

25

36

23

100

23

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

100

7

100

100

100

100

100

100

100

100

66

62

57

58

63

62

55

66

63

66

70

52

64

72

65

59

62

69

69

68

57

67

69

70

64

69

61

62

73

76

62

69

70

68

56

56

61

59

58

55

62

55

57

56

55

64

58

54

61

63

61

58

58

53

65

58

58

59

62

59

63

63

58

57

66

61

61

6469 Mexico

70 Grenada

71 Ecuador

72 Panama

73 Bosnia andHerzegovina

74 Romania

75 Azerbaijan

76 Palestine

77 Lebanon

78 Venezuela

79 Sri Lanka

80 Moldova

81 Federated Statesof Micronesia

82 DominicanRepublic

83 Tonga

84 United ArabEmirates

85 Kazakhstan

86 Armenia

87 Suriname

88 Colombia

89 Qatar

90 Brazil

91 Indonesia

92 China

93 Oman

94 Vietnam

95 Fiji

96 Belize

97 Marshall Islands

98 Paraguay

99 Tajikistan

100 Nicaragua

101 Algeria

102 El Salvador

(Figure 1 continues on next page)

Articles

16 www.thelancet.com Published online September 21, 2016 http://dx.doi.org/10.1016/S0140-6736(16)31467-2

100755025

Value

SDG index

Disaste

r

Stunting

Wasting

Overweight

MMRSBA

Under-5 m

ort

NN mort HIV

Tuberculosis

Malaria

Hepatitis B NTDs

NCDs

Suicide

Alcohol

Road injurie

s

FP need met, m

od

Adol birt

h rate

UHC tracer

Air poll m

ort

WaSH mort

Poisons

Smoking IPVWater

Sanitatio

n

Hygiene

HH air poll

Occ ris

k burden

Mean PM2·5

Violence War

MDG index

Non-MDG in

dex

45

46

46

46

46

47

47

48

48

50

50

51

53

53

53

53

53

54

54

54

55

55

55

56

56

56

57

57

57

57

58

58

58

58

31

36

27

38

15

100

21

100

53

13

47

24

100

100

100

22

100

57

100

100

32

36

100

33

29

100

100

53

100

16

29

48

39

33

47

62

70

66

70

73

48

68

73

61

71

38

68

84

34

68

96

85

84

67

53

69

57

78

85

80

76

73

89

94

84

88

90

86

76

76

84

80

83

71

67

76

80

80

84

93

73

77

51

95

93

90

94

68

83

95

80

89

84

93

77

75

90

95

92

75

86

96

93

80

51

72

77

70

96

14

69

93

40

75

48

73

88

59

65

46

68

57

97

80

81

71

71

56

82

63

65

22

46

36

77

65

29

23

34

36

34

35

37

37

48

45

59

44

51

49

30

36

72

61

58

48

45

39

30

50

61

47

39

46

52

48

51

64

61

64

47

86

95

91

91

86

81

92

89

79

92

64

89

70

49

83

99

99

99

97

95

97

58

99

99

100

96

83

99

91

99

98

99

94

35

47

42

50

51

44

48

44

51

54

60

52

56

50

44

49

80

72

71

55

59

55

41

50

81

50

50

55

64

74

60

68

63

61

30

45

42

49

55

43

46

47

46

55

63

60

53

48

45

47

83

75

73

65

58

54

32

44

80

48

44

52

64

81

59

69

62

59

34

31

6

4

41

46

28

56

61

34

49

39

63

29

44

49

40

32

31

74

46

36

47

46

34

73

20

50

54

42

49

52

46

64

42

38

9

5

54

47

38

36

53

33

65

60

73

54

36

50

54

41

41

73

50

55

35

49

45

41

43

49

64

62

54

63

63

69

24

6

59

23

13

15

16

100

100

22

100

34

100

95

16

52

100

100

100

100

38

38

59

100

26

100

19

100

100

100

100

93

83

100

35

32

35

35

17

33

35

17

32

32

32

72

46

33

32

69

49

49

49

43

15

72

50

41

33

41

76

32

32

17

41

46

60

43

80

86

61

73

65

63

99

66

99

66

96

71

93

99

83

82

100

99

100

86

94

75

90

87

87

100

87

92

95

97

100

96

99

97

44

44

43

45

24

48

46

22

35

46

59

70

46

60

61

67

36

41

42

58

42

59

65

40

61

30

37

60

69

47

43

83

56

73

42

76

43

34

38

85

45

36

61

70

75

63

84

39

55

49

21

21

34

92

45

68

65

46

42

19

24

62

75

54

63

86

70

81

88

97

66

69

93

76

79

88

96

77

97

88

96

76

87

77

0

7

8

95

83

81

93

75

74

72

68

97

94

85

72

97

94

90

40

59

29

42

50

55

47

62

45

66

44

55

57

67

60

52

50

53

62

59

39

55

67

50

36

47

46

49

51

69

54

40

27

66

50

50

91

88

65

34

53

64

44

50

52

60

86

75

41

50

81

75

76

57

62

80

57

61

66

76

65

78

72

69

56

59

74

70

42

70

57

56

49

35

45

69

34

43

84

36

43

41

46

41

70

67

66

51

93

43

65

49

54

65

35

59

81

60

54

81

64

61

48

60

79

82

58

78

57

81

71

57

78

56

80

80

55

65

94

85

82

78

77

68

75

88

69

87

76

80

88

71

86

85

90

82

36

40

51

46

40

35

39

62

50

44

58

56

49

50

48

59

57

62

57

60

39

49

47

46

61

41

60

70

69

65

52

62

60

71

36

37

32

29

41

33

39

29

57

43

62

37

56

43

42

46

93

79

89

68

69

44

38

66

49

75

46

57

64

54

82

61

67

76

55

53

55

49

47

55

60

49

65

85

62

50

65

59

63

39

39

47

43

60

45

54

68

54

69

40

59

58

67

60

57

63

41

80

34

63

66

74

63

93

58

13

69

50

71

83

62

87

37

51

35

41

40

65

57

79

86

59

60

51

80

82

54

43

51

72

77

47

73

64

78

59

54

53

84

35

78

88

50

73

60

61

54

58

75

64

73

50

96

73

53

54

57

80

73

50

50

49

95

50

31

53

38

31

31

24

19

11

32

24

23

32

26

30

21

15

65

63

85

86

77

19

50

40

75

41

34

31

33

18

16

40

23

30

30

29

66

42

71

44

48

41

49

60

91

88

92

67

97

56

40

63

84

79

78

88

58

69

63

38

98

43

69

78

92

94

70

96

86

87

22

27

20

16

26

4

21

27

22

48

20

31

26

6

28

33

68

69

65

22

33

40

5

60

46

58

29

13

26

48

70

37

32

28

49

53

85

64

61

35

53

80

99

70

99

69

100

64

51

85

99

98

97

100

59

69

71

81

88

68

94

97

100

72

80

100

100

98

33

30

64

42

31

44

31

46

65

45

54

53

66

55

55

42

66

67

60

73

38

52

27

42

54

42

61

52

49

57

41

83

68

51

40

27

43

56

75

63

43

95

28

49

16

39

8

36

55

44

52

58

54

34

39

37

26

57

46

49

57

49

32

92

52

8

33

37

87

59

10

32

70

39

56

17

22

25

64

9

53

26

55

37

32

25

38

61

56

6

73

39

34

33

21

57

65

48

52

86

57

58

100

14

22

100

100

100

100

100

1

35

1

100

6

100

100

100

100

31

3

0

100

100

100

100

100

100

100

100

9

100

100

54

100

19

43

43

49

41

46

39

45

55

56

51

64

50

61

50

43

58

82

75

73

59

61

58

56

58

63

59

51

56

63

69

60

68

67

67

47

47

43

47

46

48

49

40

46

51

44

53

49

52

57

52

45

46

48

52

51

55

51

56

54

55

60

56

55

49

57

52

55

54103 Turkey

104 Iran

105 Saudi Arabia

106 Georgia

107 Samoa

108 Tunisia

109 Morocco

110 Guyana

111 Mongolia

112 Thailand

113 Kyrgyzstan

114 Bhutan

115 Honduras

116 North Korea

117 Syria

118 Ukraine

119 Russia

120 Belarus

121 Bolivia

122 Timor-Leste

123 Cape Verde

124 Egypt

125 Guatemala

126 Libya

127 Philippines

128 Iraq

129 Kiribati

130 Cambodia

131 São Toméand Príncipe

132 Vanuatu

133 Botswana

134 South Africa

135 Myanmar

136 Laos

(Figure 1 continues on next page)

Articles

www.thelancet.com Published online September 21, 2016 http://dx.doi.org/10.1016/S0140-6736(16)31467-2 17

100755025

Value

SDG index

Disaste

r

Stunting

Wasting

Overweight

MMRSBA

Under-5 m

ort

NN mort HIV

Tuberculosis

Malaria

Hepatitis B NTDs

NCDs

Suicide

Alcohol

Road injurie

s

FP need met, m

od

Adol birt

h rate

UHC tracer

Air poll m

ort

WaSH mort

Poisons

Smoking IPVWater

Sanitatio

n

Hygiene

HH air poll

Occ ris

k burden

Mean PM2·5

Violence War

MDG index

Non-MDG in

dex

32

32

32

33

33

34

34

34

35

35

35

36

36

36

36

36

36

37

37

38

38

38

38

40

40

41

41

42

42

43

43

44

44

45

32

29

26

55

100

100

100

42

100

49

50

43

9

100

100

32

58

100

53

52

100

28

32

31

37

27

54

36

100

100

100

100

14

19

62

51

39

45

54

36

64

53

38

56

50

66

45

74

68

51

45

41

32

48

66

38

59

59

63

69

71

46

53

73

60

74

63

66

80

88

82

91

77

60

77

58

59

72

44

79

64

88

66

86

81

80

46

56

65

61

96

89

86

80

75

51

57

82

44

87

86

74

56

78

77

62

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46137 Namibia

138 Solomon Islands

139 Gabon

140 Djibouti

141 Ghana

142 Comoros

143 India

144 Senegal

145 Haiti

146 Kenya

147 Zimbabwe

148 Swaziland

149 Pakistan

150 Mauritania

151 Bangladesh

152 Yemen

153 Zambia

154 Tanzania

155 Papua NewGuinea

156 The Gambia

157 EquatorialGuinea

158 Nepal

159 Congo

160 Sudan

161 Côte d’Ivoire

162 Eritrea

163 Nigeria

164 Togo

165 Benin

166 Liberia

167 Rwanda

168 Malawi

169 Lesotho

170 Angola

(Figure 1 continues on next page)

Articles

18 www.thelancet.com Published online September 21, 2016 http://dx.doi.org/10.1016/S0140-6736(16)31467-2

improvement for the indicator on malaria incidence represents the large number of malaria-free countries in both 2000 and 2015.46 Health-related indicators covered by Target 3.3—which aims to end the epidemics of HIV, tuberculosis, malaria, and neglected tropical diseases, and to “combat hepatitis” by 2030—generally saw moderate progress (median absolute change of 2∙7 [IQR –0∙2 to 4∙6] for HIV incidence and 3∙9 [IQR 1∙7 to 5∙7] for tuberculosis incidence), although minimal changes occurred for hepatitis B incidence (–0∙2 [–0∙4 to –0∙05]). In combination, these trends highlight the need for accelerated progress in order to meet Target 3.3. Substantial improvements occurred for childhood stunting (8∙2 [3∙5 to 14∙2]) and, to a more modest extent, wasting (2∙7 [0∙0 to 6∙0]), yet childhood overweight considerably worsened in the past 15 years (–4∙5 [–9∙2 to –0∙7]). This trend occurred across SDI

quintiles, emphasising the need for concerted policy attention to reverse this trend. Alcohol consumption worsened slightly in the past 15 years as well (–0∙4 [–2∙3 to 0∙7]).

Between 2000 and 2015, distinct patterns for absolute changes in health-related SDG indicators surfaced across SDI quintiles (fi gure 6). While the indicator for UHC tracer interventions improved across all SDI quintiles, the most pronounced gains occurred in low-SDI and low-middle-SDI countries. Childhood stunting and wasting also improved at a faster pace for the low-SDI quintile than for other quintiles. Notably, mortality measures from the MDG agenda—maternal mortality ratio, under-5 mortality, and neonatal mortality—progressed at a similar pace across SDI quintiles. By contrast, mortality due to road injuries, non-communicable diseases (NCDs), and interpersonal

Figure 1: Performance of the health-related SDG index, MDG index, and non-MDG index, and 33 individual health-related indicators, by country, 2015Countries are ranked by their health-related SDG index from highest to lowest. Indicators have been scaled from 0 to 100. Defi nitions of health-related SDG indicators are shown in table 1. SDG=Sustainable Development Goal. MDG=Millennium Development Goal. MMR=maternal mortality ratio. SBA=skilled birth attendance. Mort=mortality. NN mort=neonatal mortality. NTDs=neglected tropical diseases. NCDs=non-communicable diseases. FP need met, mod=family planning need met, modern contraception. Adol=adolescent. UHC=universal health coverage. Air poll mort=mortality attributable to air pollution. WaSH=water, sanitation, and hygiene. IPV=intimate partner violence. HH air poll=household air pollution. Occ risk burden=burden attributable to occupational risks. PM2·5=fi ne particulate matter smaller than 2·5 μm.

100755025

Value

SDG index

Disaste

r

Stunting

Wasting

Overweight

MMRSBA

Under-5 m

ort

NN mort HIV

Tuberculosis

Malaria

Hepatitis B NTDs

NCDs

Suicide

Alcohol

Road injurie

s

FP need met, m

od

Adol birt

h rate

UHC tracer

Air poll m

ort

WaSH mort

Poisons

Smoking IPVWater

Sanitatio

n

Hygiene

HH air poll

Occ ris

k burden

Mean PM2·5

Violence War

MDG index

Non-MDG in

dex

20

22

22

23

24

24

26

26

26

27

28

28

29

29

30

31

31

31

100

25

28

31

52

48

30

47

18

42

28

32

100

100

100

53

58

57

45

44

54

36

48

43

21

49

33

46

33

44

54

53

41

55

53

58

71

55

30

42

47

71

78

54

66

67

39

79

77

66

64

82

50

80

84

86

72

90

82

84

92

75

88

68

87

71

71

82

88

82

78

68

12

17

20

24

20

21

24

25

13

15

26

27

21

17

23

28

25

21

61

32

41

32

21

87

63

57

40

61

44

61

39

49

15

68

68

67

19

22

23

22

19

27

30

19

28

20

34

29

20

22

35

32

22

27

17

26

29

34

21

30

32

17

29

21

35

32

20

22

32

34

27

25

15

34

23

34

23

26

24

25

57

26

46

11

18

23

26

15

28

17

24

30

28

35

33

30

34

40

45

36

41

24

30

36

32

29

36

36

3

11

6

3

7

3

6

1

14

2

9

3

10

2

25

5

2

4

34

36

31

33

33

32

35

33

31

34

31

37

33

33

36

33

33

34

68

48

58

97

70

47

79

90

76

78

57

59

74

56

55

85

93

75

26

42

51

57

50

47

47

51

10

45

39

44

46

45

52

46

52

47

35

53

55

61

55

53

49

65

55

54

52

43

53

55

50

43

50

45

85

96

82

96

81

87

71

96

96

73

91

89

82

94

79

58

67

74

23

42

44

59

47

50

37

58

13

47

53

40

48

53

49

35

46

48

9

15

24

29

16

14

29

20

39

35

37

38

20

18

54

41

28

33

33

27

41

5

19

23

53

12

37

25

26

20

33

20

43

24

27

29

45

16

27

46

34

56

65

47

28

64

39

59

52

48

44

69

66

58

15

28

32

30

27

27

31

39

11

28

29

37

26

27

38

33

34

31

14

6

9

16

14

23

16

21

38

21

21

20

19

21

20

22

19

25

32

27

33

42

39

42

34

44

44

42

41

39

39

42

44

37

42

46

86

84

83

91

85

84

89

88

66

71

77

78

87

92

92

87

81

90

74

53

53

61

79

12

53

50

50

23

53

42

61

61

27

18

84

23

2

5

6

2

2

3

4

4

9

3

19

6

3

7

8

26

4

7

9

26

8

3

8

15

11

13

28

17

4

11

24

20

7

20

11

24

0

1

1

1

2

0

1

1

4

2

3

1

1

1

1

3

1

5

2

1

1

2

3

3

2

2

49

2

2

4

3

2

4

2

6

24

21

43

42

40

33

30

29

49

43

39

20

31

35

35

37

31

30

40

31

53

40

23

31

31

32

32

30

54

53

54

40

50

38

24

35

21

34

26

31

53

48

47

74

55

11

65

60

37

38

49

38

37

80

53

3

1

2

4

6

7

5

7

1

100

12

28

100

33

17

100

100

4

15

19

18

13

15

20

23

18

26

20

23

22

21

21

23

33

21

26

24

24

24

28

30

25

27

30

27

30

29

30

33

33

32

29

35

34171 Cameroon

172 Burkina Faso

173 Uganda

174 Ethiopia

175 Guinea

176 Guinea-Bissau

177 Mozambique

178 Madagascar

179 Sierra Leone

180 Afghanistan

181 Mali

182 Burundi

183 DemocraticRepublic ofthe Congo

184 Chad

185 Niger

186 South Sudan

187 Somalia

188 Central AfricanRepublic

Articles

www.thelancet.com Published online September 21, 2016 http://dx.doi.org/10.1016/S0140-6736(16)31467-2 19

violence declined faster in the higher-SDI quintiles than in the lower-SDI quintiles. Prevalence of smoking also had the largest reductions in countries in the high-SDI quintile.

Between 2000 and 2015, progress on the health-related SDG index (fi gure 7), as well as on individual health-related SDG indicators and on the MDG and non-MDG indices (results appendix p 6), was highly heterogeneous across geographies. Since 2000, the largest absolute improve ments in the health-related SDG index occurred in Timor-Leste (18∙5, 95% UI 16∙2–20∙8), Bhutan (16∙2, 13∙6–18∙7), and Colombia (15∙6, 14∙1–16∙8), whereas three countries—Libya, Syria, and Chile—experienced signifi cant declines. Declines for the next two countries (Brunei and South Sudan) were between 0 and –0∧5 and rounded to 0 in fi gure 7. Countries with the most pronounced gains for the health-related SDG index were found mainly in east, southeast, and central Asia, as well as parts of Latin America (eg, Venezuela and Honduras). Several countries in sub-Saharan Africa also recorded considerable gains in the health-related SDG index, including Rwanda, Ethiopia, Ghana, Namibia, and Angola.

To demonstrate the usefulness of these estimates for informing progress towards the SDGs, we also identifi ed

the geographies with the largest improvement in overall health-related SDG index between 2000 and 2015, stratifi ed by SDI quintile classifi cation in 2000. The fi ve geographies were: Timor-Leste in the low-SDI quintile, Tajikistan in the low-middle-SDI quintile, Colombia in the middle-SDI quintile, Taiwan (province of China) in the middle-high-SDI quintile, and Iceland in the high-SDI quintile. Based on their gains for the health-related SDG index, these geographies could serve as case studies for understanding potential drivers of progress on the SDGs.

In Timor-Leste, changes in the health-related SDG index were largely driven by improvements in UHC tracer interventions, skilled birth attendance, met need with modern contraception, under-5 and neonatal mortality, childhood stunting, risk exposure to unsafe water and sanitation, and mortality from war or confl ict. This overall improvement was despite worsening measures for childhood overweight, smoking prevalence, and alcohol use since 2000. Tajikistan recorded sizeable improvements across various health-related SDG indicators. Among indicators related to the MDGs, these included both measures of child mortality, childhood stunting, coverage of UHC tracer interventions, malaria incidence, and exposure to household air pollution. Improvements were also noted

Figure 2: Map of health-related SDG index, by quintile, 2015SDG=Sustainable Development Goal. ATG=Antigua and Barbuda. VCT=Saint Vincent and the Grenadines. LCA=Saint Lucia. TTO=Trinidad and Tobago. TLS=Timor-Leste. FSM=Federated States of Micronesia.

Persian GulfCaribbean LCA

Dominica

ATG

TTO

Grenada

VCT

TLS

Maldives

Barbados

Seychelles

Mauritius

ComorosWest Africa Eastern

Mediterranean

Malta

Singapore Balkan Peninsula Tonga

Samoa

FSM

Fiji

Solomon Isl

Marshall Isl

Vanuatu

Kiribati

Health-related SDG index <37·8 37·8–55·7 55·7–62·5 62·5–71·5 ≥71·5

Articles

20 www.thelancet.com Published online September 21, 2016 http://dx.doi.org/10.1016/S0140-6736(16)31467-2

in mortality due to NCDs, interpersonal violence, and war or confl ict, as well as mortality attributable to unsafe water, sanitation, and hygiene and to air pollution. However, several indicators either had minimal progress or worsened in Tajikistan, particularly childhood overweight and intimate partner violence. Colombia’s most pronounced improvements since 2000 occurred

for many of the non-MDG indicators, which included smoking prevalence and mortality rates due to NCDs, road injuries, interpersonal violence, and war. Sizeable improvements were also recorded for a subset of health-related MDG indicators—namely, coverage of UHC tracer interventions, adolescent birth rates, met need with modern contraception, and unsafe sanitation.

Figure 3: Non-MDG index versus MDG index, by country, 2015The dark blue line shows the equivalence line, such that values that fall on this line are equivalent for both the MDG index and non-MDG index. Countries are abbreviated according to the ISO3 code. MDG=Millennium Development Goal. SDI=Socio-demographic Index.

20 40 60 80 100

20

40

RWA

MDV

PANDOM

SUR

BLZ

NIC

TJK

MARKGZ

HND

SYR

MNG

GEO

DZA

MHL

THATUN

PRY

ARMVEN

COL

VNMBRA

FJI

SLVOMN

IRNTUR CHN

QATTON

SAU

AZEPSE

TKM

LCA

VCT

BRB

TTOBHS

JORSYC

MYS

MUS HRVCRIMEX

PER

ECU GRDCUB

MKD

SRB

KWTBIH

BGR

ARG MNE

ROULBN ARE

KAZBHR

LKA

MDAFSM

JAMALB

UZB

DMA

UGAAFG

CAF SOMSSD

NERMLI

SLE ETHMDG

BDI

MOZTCD

COD

NGA

TLS

IDN

GUY

GTMCPV

PHL BTN

IRQ

KIR

PRKBOLEGY

LBY

WSMUKR

RUS BLR

ATG

SGPSWE

ISLGBR

ANDNLDAUS

NORIRL

BELDEU CYP

DNKCHE

LUXCAN

ESPMLT

USA PRT ITAJPNFRA

ISR

GRC

AUTKOR

CZE

NZLSVN

SVKHUN

EST

FIN

MRT

GHA

HTI

GAB

IND

NAMBWA

STPKHM

LAOMMB VUT

SLBZAFDJI

SEN

COM

SDNCIV

ERI

TGO

LBR

CMRAGO

MWI LSO

COGTZA

GMBPNG

ZMB NPL

YEMZWE

KENBGDSWZ

PAK

GNQ

LTUPOL

URYTWN

BRN

LVACHL

BENBFA

GNB GIN

60

80

100

Non

-MDG

inde

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www.thelancet.com Published online September 21, 2016 http://dx.doi.org/10.1016/S0140-6736(16)31467-2 21

Nonetheless, similar to other countries, Colombia had minimal progress in or worsened levels of alcohol consumption and hepatitis B incidence. In Taiwan, marked gains occurred for a subset of health-related SDG indicators previously associated with the MDG agenda (eg, adolescent birth rates and coverage of UHC tracer interventions); in parallel, Taiwan had considerable improvements for many non-MDG indicators, such as smoking prevalence and mortality due to NCDs, interpersonal violence, and road injuries. However, HIV and hepatitis B incidence worsened in Taiwan since 2000, and minimal progress occurred for

ambient particulate matter pollution and several maternal and child health indicators. For Iceland, its progress on the health-related SDG health index was primarily driven by improvements in mortality due to NCDs and road injuries, smoking prevalence, adolescent birth rates, and both measures of child mortality. Similar to other countries, particularly those in the high-middle-SDI and high-SDI quintiles, Iceland had little progress in childhood overweight and worsening levels of alcohol consumption.

Further results are provided in the results appendix, and dynamic visualisations are available online.

Figure 4: Relations (A) between the SDI and the health-related SDG index, (B) between the SDI and the MDG index, (C) between the SDI and the non-MDG index, and (D) between healthy life expectancy and the health-related SDG index, by country representing each of the seven GBD super regions, 2015 Each point represents a country and is colour coded according to the seven GBD super regions. The black lines were generated by spline regression. SDG=Sustainable Development Goal. SDI=Socio-demographic Index. MDG=Millennium Development Goal. GBD=Global Burden of Disease.

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For dynamic visualisations of results see https://vizhub.healthdata.org/sdg

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22 www.thelancet.com Published online September 21, 2016 http://dx.doi.org/10.1016/S0140-6736(16)31467-2

DiscussionSummary of fi ndings and implicationsThe ambitious SDG agenda is accompanied by numerous goals, targets, and indicators for tracking progress. Leading up to and following the UN SDG resolution1 in September, 2015, considerable debate surrounded the selection of indicators, including scepticism about the feasibility of their measurement.5,6 In this study, we produced independent, highly standardised, and comparable estimates of 33 of the 47 health-related SDG indicators across 188 countries. To facilitate overall tracking, we also distilled these 33 health-related indicators into a health-related SDG index. Our fi ndings show the wide range in this health-related SDG index in 2015, from 20∙4 in Central African Republic to 85∙5 in Iceland. Our historical analysis of these indicators also shows that progress can be achieved. Notable improvements were recorded for several health-related SDG indicators, particularly those that were also MDG indicators, such as under-5 mortality, met need with modern contraception, and childhood stunting. An index of the 14 MDG indicators that were included in the health-related SDG indicators

had a median absolute change of 10∙0 from 2000 to 2015, and larger reductions were generally found for countries at the lower end of the development spectrum. Our analysis also highlights the challenges associated with the expanded scope of the SDGs, with several of the non-MDG indicators having minimal improvements (eg, hepatitis B incidence) or worsening (eg, childhood overweight) between 2000 and 2015. This fi nding is further supported by the highly variable relation between the health-related MDG index and the health-related non-MDG index—good performance on the MDG index did not guarantee good performance on the non-MDG index. The overall health-related SDG index was well predicted by SDI; however, SDI was a variable predictor of the performance of individual health-related SDG indicators, particularly indicators that were not in the MDG agenda. Drawing from GBD, these fi ndings provide a strong, comparable basis for monitoring the SDGs; furthermore, the independent nature of these results can enable accountability mechanisms for the multiple national and international, governmental, and non-governmental actors that must achieve progress on the SDGs.

Figure 5: Map of observed health-related SDG index minus expected health-related SDG index, on the basis of SDI alone, 2015The diff erence between the observed health-related SDG index and expected index (on the basis of SDI) refl ects whether a country has a health-related SDG index above or below the expected level. Values for this diff erence are colour coded such that dark red refl ects an observed health-related SDG index that is much lower than expected on the basis of SDI, and dark blue indicates that observed levels are much higher than expected on the basis of SDI. SDG=Sustainable Development Goal. SDI=Socio-demographic Index. ATG=Antigua and Barbuda. VCT=Saint Vincent and the Grenadines. LCA=Saint Lucia. TTO=Trinidad and Tobago. TLS=Timor-Leste. FSM=Federated States of Micronesia.

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Figure 6: Median absolute change for health-related SDG index, MDG index, and 33 individual health-related SDG indicators (rescaled), (A) across all countries and in the (B) low-SDI quintile, (C) low-middle-SDI quintile, (D) middle-SDI quintile, (E) high-middle-SDI quintile, and (F) high-SDI quintile, 2000–15Positive values indicate improvements between 2000–15, and negative values point to worsening performance for a given indicator during this time. Black stripes represent median absolute change and boxes represent IQR. Health-related indicators are colour coded according to the health-related goals they represent. Defi nitions of health-related SDG indicators are shown in table 1. SDG=Sustainable Development Goal. MDG=Millennium Development Goal. SDI=Socio-demographic Index. MMR=maternal mortality ratio. SBA=skilled birth attendance. Mort=mortality. NN mort=neonatal mortality. NTDs=neglected tropical diseases. NCDs=non-communicable diseases. FP need met, mod=family planning need met, modern contraception. Adol=adolescent. UHC=universal health coverage. Air poll mort=mortality attributable to air pollution. WaSH=water, sanitation, and hygiene. IPV=intimate partner violence. HH air poll=household air pollution. Occ risk burden=burden attributable to occupational risks. PM2·5=fi ne particulate matter smaller than 2·5 μm.

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24 www.thelancet.com Published online September 21, 2016 http://dx.doi.org/10.1016/S0140-6736(16)31467-2

These estimates also allow the identifi cation of places that have made substantial progress on the health-related SDG indicators. These fi ndings stand to strengthen the global evidence base of lessons learned for accelerating improvements in the health-related SDGs. The fi ve geographies with the greatest improvement in the health-related SDG index between 2000 and 2015, stratifi ed by SDI quintiles (Timor-Leste, Tajikistan, Colombia, Taiwan, and Iceland), have implemented a range of policies and interventions that might have contributed to their progress.

For instance, following acute confl ict and violence during the late 1990s, Timor-Leste, in concert with the World Bank and other development partners, implemented a series of health sector rehabilitation and development projects in 2000 and 2001 to re-establish the country’s health system and improve health service delivery to the poor.47,48 In more recent years, health-care reform and fi nancing have topped policy agendas in Timor-Leste,49 including the Ministry of Health’s roll-out of a Basic Health Services Package and Hospital Services

Package in 2007 under the pursuit of achieving UHC.50 Following almost a decade of civil confl ict that severely disrupted health service provision, Tajikistan launched a series of health reforms beginning in the late 1990s51 and introduced a new benefi ts package for guaranteed health services in 2007.52 Moreover, after the civil war, the Tajik Government refocused policy attention for initiatives on particular diseases such as malaria;53 indeed, the country’s multipronged malaria programme, which emphasises strong surveillance and cross-border activities with Afghanistan,54 has now brought Tajikistan close to eliminating the disease. Colombia, which experienced ongoing confl ict and violence from the late 1980s to 2003,55 is globally recognised for its expansion of health insurance and services, especially to the poor. While Colombia’s health system reforms began well before 2000 (the country approved its universal health insurance scheme in 1993),56 coverage increased substantially over time, as have the types of services covered by its insurance scheme (eg, cancer care).57 During the mid-1990s, Taiwan adopted a universal

Figure 7: Health-related SDG index in 2015 versus 2000, by countryThe blue line shows the equivalence line, such that values that fall on this line are equivalent for both the health-related SDG index in 2000 and health-related SDG index in 2015. Only the top fi ve and bottom fi ve improvers in each SDI quintile, as determined by the absolute change from 2000 to 2015, are labelled; full results are shown in the results appendix. Countries are abbreviated according to the ISO3 code. SDI=Socio-demographic Index. SDG=Sustainable Development Goal.

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health insurance system,58 which is viewed as one of its most successful public entities. Taiwan also enacted many road safety laws between the mid-1990s and early 2000s, including mandatory helmet laws for motorcyclists in 1996 and an extension of seat belt laws to general roads in 2001.59 Iceland’s tobacco control policies have been viewed as some of the world’s most comprehensive,60 and the country’s long-standing publicly funded health system provides UHC,61 a factor that might have contributed to its declines in NCD mortality.

Such progress also highlights important interactions between development goals and wider contextual factors, such as post-confl ict experiences in Timor-Leste, Tajikistan, and Colombia, as well as a rebound in health following the dissolution of Soviet rule for Tajikistan. Furthermore, Taiwan’s gains underscore the interplay between advancing economic development and deliberate investments in improving UHC. These vignettes highlight only a fraction of the possible learning for informing action towards improving the health-related SDGs. An important future area of work will be to understand in detail how these and other high-performing geographies have achieved substantial improvements in key SDG indicators.

Besides showing the feasibility and value of measuring many of the health-related SDGs, our fi ndings also affi rm concerns voiced during the SDG development process and following the UN resolution. One criticism of the SDGs was the incredibly ambitious nature of some of the targets,5 such as Target 3.3, which calls for the end of the epidemics of HIV, tuberculosis, and malaria by 2030. Our analysis of these indicators in the past 15 years suggests that a substantial change in the present trajectory of HIV and tuberculosis incidence will be needed to meet this target, and major technological leaps coupled with universal delivery are likely to be necessary. The vague nature of many of the SDG targets has also been a common criticism;4,8,10,62 Of the 33 health-related SDG indicators in our study, we identifi ed specifi c targets for only 21 of them. The absence of specifi c and attainable targets for SDG indicators, health related or otherwise, undermines the usefulness of the SDGs in driving development agendas, a limitation that can and should be addressed at this early stage of the SDG period.

Our analysis also represents a step towards producing a more cohesive understanding of the interactions between diff erent SDG goals, targets, and indicators—a widely noted criticism.3,4 We show the potential for quantifying these interactions by comparing the relations between education, income, and fertility—components of the SDI—and the 33 health-related SDG indicators and accompanying health-related SDG, MDG, and non-MDG indices. Although we acknowledge the ecological nature of this analysis and its usual caveats, SDI was a strong predictor of the overall

health-related SDG and MDG indices, highlighting the general importance of income, education, and fertility, as well as intersectoral action for health-related development. However, SDI was a weaker predictor of the non-MDG index, particularly for indicators such as violence (intimate partner, interpersonal, and collective violence) and ambient particulate matter pollution. This fi nding shows that a sole focus on increasing income and education and decreasing fertility is probably insuffi cient to meet the SDG targets. It also raises questions about whether other common drivers, analogous to income, education, and fertility, can be determined and their relations with SDG indicators assessed. Combining this initial assessment of the 33 health-related SDG indicators with an expanded quantifi cation and analysis of other potential drivers is an important future area of work that could help to create a more concise, cohesive, and actionable monitoring framework for the SDGs.

Future directions for GBD monitoring eff ortsIn this report, we focused on measuring indicators proposed by the IAEG-SDGs. In future years, we plan to address three related sets of issues: fi rst, improved assessment of the health-related SDG indicators measured at present; second, inclusion of the 14 currently excluded health-related indicators in the annualised GBD study; and third, potential expansion of indicators consistent with the framing of the targets. We address each of these issues in turn.

Improving the measurement of currently included health-related indicatorsWith the present analysis, we made several modifi cations that we believe improve several health-related indicators for the purposes of measuring progress towards each health-related SDG target. Future iterations are likely to incorporate further modifi cations to these and other indicators. First, as noted in the Methods section, rather than reporting on the combined prevalence of childhood wasting and overweight, we assessed and measured them separately. Our results support this decision, since they had divergent relations over time (ie, childhood wasting improved for most countries, whereas the prevalence of childhood overweight generally increased) and with SDI (ie, childhood wasting and overweight were negatively and positively correlated with SDI, respectively).

Second, the IAEG-SDGs’ proposed indicator for harmful use of alcohol is the average national-level consumption per person in litres of pure alcohol. The health and non-health risks associated with harmful alcohol use are a function of not only average consumption at the population level but also use patterns (ie, amount consumed at a given time and frequency of consumption). For this analysis, we reported on the summary exposure value of harmful alcohol use, which

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26 www.thelancet.com Published online September 21, 2016 http://dx.doi.org/10.1016/S0140-6736(16)31467-2

takes into account the distribution of consumption and the prevalence of binge drinking.39

Third, we made two modifi cations to the measurement of disaster (Indicators 1.5.1, 11.5.1, and 13.1.2). For mortality attributable to disasters, we chose to report on the lagged 5 year average of disaster mortality. One of the corresponding health-related SDG targets (Target 1.5) is to “build the resilience of the poor and those in vulnerable situations and reduce their exposure and vulnerability to climate-related extreme events and other economic, social and environmental shocks and disasters”. Focusing solely on the observed mortality caused by natural disaster ignores the role of chance in the occurrence of natural disasters; for example, nations with weak resilience to natural disasters might not experience a natural disaster during a given period of time, whereas those with strong resilience might encounter them more frequently. Taking the moving average of disaster mortality lessens the contribution of chance in assessing progress for this indicator. Nonetheless, this adjustment cannot account for background risk of natural disasters, which varies by geography, and future research eff orts could include developing a risk-standardised version of the indicator. For natural disasters, data on missing people and people aff ected by disaster are not readily available across countries and over time.

Fourth, for occupational health (Indicator 8.8.1), we reported on age-standardised all-cause DALY rate attributable to occupational risks rather than the suggested indicator, which is limited to fatal and non-fatal occupational injuries. This revision captures a wider set of occupational risks instead of only those that result in injuries, which supports the stated target of promotion of “safe and secure working environments for all workers” (Target 8.8). Fifth, for tobacco use prevalence (Indicator 3.a.1), GBD does not presently assess smokeless tobacco use. Furthermore, smokeless tobacco use has a notably diff erent risk profi le to smoked tobacco use,63 and thus it might warrant a subindicator akin to childhood malnutrition. Sixth, for clean fuels and technology (Indicator 7.1.2), we presently use a more limited defi nition that covers fuels used primarily for household cooking. Seventh, for homicide (Indicator 16.1.1), GBD does not measure this indicator by displacement or migratory status, and similarly for confl ict-related deaths (Indicator 16.1.2), we do not measure deaths by displacement status or by more specifi ed causes.

Eighth, data gaps also account for limitations in the estimation of the UHC tracer indicator (Indicator 3.8.1). We used a set of tracer interventions that were restricted to reproductive, maternal, and child health, as well as a subset of infectious diseases. There is a paucity of data for the coverage of NCD interventions in particular64–67 and for higher-level care. Furthermore, the UHC tracer indicator only captures the use of interventions and not the quality of the intervention provided.68,69 As more data

become available on the delivery of interventions for NCDs and the modifi cation of key risk factors, this information will be incorporated into revisions of the UHC tracer indicator. Finally, data gaps mean that, in this initial assessment, we have also not been able to include a measure of fi nancial risk protection. Substantial investments are needed in this area to address data gaps to be able to track the central role of health system delivery in improving health.

Indicators not presently measuredOf the 14 health-related SDG indicators that were not included in this analysis, there are several that the GBD does not currently measure but that could be assessed in the future through GBD (table 2). These indicators include the coverage of treatment interventions for substance use disorders (Indicator 3.5.1), which would leverage the work on quantifying incidence, prevalence, and mortality for these conditions. Estimating the proportion of women and girls aged 15 years and older who are subjected to sexual violence by people other than an intimate partner (Indicator 5.2.2) would leverage work already undertaken by GBD on measuring prevalence of intimate partner violence. As part of GBD, we have also assembled a host of population-level data that would facilitate measurement of the coverage of health insurance or public health systems (Indicator 3.8.2), health worker density and distribution (Indicator 3.c.1), and completeness of death registration (Indicator 17.19.2). Other indicators are more diffi cult to measure because of data gaps or unclear defi nitions. For example, data sources to measure the proportion of people that feel safe walking alone around the area they live (Indicator 16.1.4) are not readily available for most countries.

Strengthening the indicators for selected targetsVarious commentaries have pointed out the absence of indicators for key health outcomes and determinants. Proponents have argued for indicators for mental health that go beyond substance abuse disorders and suicide;14–16 other NCDs beyond cardiovascular diseases, cancer, diabetes, and chronic respiratory diseases;70 diseases related to ageing, including osteoarthritis and Alzheimer’s disease;71,72 non-fatal disorders that lead to substantial morbidity (eg, sensory disorders); and a host of major risk factors. Another example is Target 3.3, which aims to combat hepatitis—the indicator only tracks hepatitis B, although the data for hepatitis C monitoring are as robust as those for hepatitis B and a highly eff ective cure for hepatitis C is available. As shown in this report, our GBD collaboration provides the basis for measuring many of these indicators. The danger is that an exhaustive laundry list of indicators, a criticism already levelled at the present SDG list, would dilute the value of the SDGs in focusing attention on where it is most needed.

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Comparison with other assessmentsThere are several important similarities and diff erences between our assessment of the health-related SDGs and those produced by WHO18 and the Sustainable Development Solutions Network (SDSN).17 Like WHO, we focused on the health-related SDG indicators and did not cover indicators across all goals as SDSN does. With our focus on health, we covered 33 health-related indicators, compared with 21 by SDSN and 32 by WHO. Similar to SDSN, we produced a summary measure for the health-related SDG indicators included in the analysis. Most importantly, GBD uses standardised and internally consistent approaches to generate estimates across causes, risk factors, and underlying indicators. For example, we constrain the aggregation of cause-specifi c deaths to equal all-cause deaths. Furthermore, GBD also produces a complete set of estimates for 188 countries and for individual years from 1990 to 2015. By contrast, WHO and SDSN draw on disparate sources and methods for estimation and, as a result, report on an incomplete set of estimates by country. SDSN provides estimates for 149 countries, whereas estimates for health-related SDG indicators produced by WHO range from 194 countries for under-5 mortality and neonatal mortality to 109 countries for HIV incidence. WHO and SDSN also do not generate estimates for a consistent set of years. WHO reports 2015 estimates for only seven indicators and combines data from a range of years for ten indicators; for example, WHO combined skilled birth attendance estimates by country ranging from 2006 to 2014. SDSN reports 2015 estimates for only four indicators and combines data from a range of years for eight indicators; for example, country estimates for smoking prevalence from the SDSN report range from 2006 to 2013. Complete, consistent, comparable, and contemporary estimates of health-related SDG indicators are necessary to properly track progress on the SDGs.

LimitationsThis study has several limitations in addition to the ones we already described. First, all the limitations of GBD relevant to the 33 indicators used here apply.34,37–39 Second, we tried to summarise the complexity of the 33 indicators using a summary measure for the health-related SDGs. Many approaches are available for developing summary measures. Since the SDGs are the outcome of a political consensus building process, we opted to use the stated targets as preferences of UN member states that have agreed to the SDG declaration. Our sensitivity analysis shows that using alternative weighting schemes produces broadly similar results (methods appendix pp 312–13). Our sensitivity analysis also highlights the limitation of the statistical approach (ie, principal component analysis) for constructing an index for this purpose, with the fi rst principal component including both positive correlations with indicators such as maternal mortality ratio and negative correlations with indicators such as alcohol use.

An alternative could be to weight each indicator by their contribution to healthy life expectancy. Third, we opted to construct the summary measure using the Human Development Index method of rescaling each component on a scale of 0 to 100, and then taking the geometric mean of the components. We chose to use the minimum and maximum observed values to rescale, as targets for all indicators are not clearly specifi ed; however, the limitation of this approach is that minimum and maximum values might change in the future. In the next iteration of this analysis, we will use targets for all indicators and rescale them accordingly; to establish targets for indicators currently lacking explicit ones, we will determine plausible targets based on forecasts of trends through 2030. Fourth, a clear limitation, as highlighted by the UHC tracer indicator, is the need for broad investment in data systems in countries to properly assess progress on key health and development indicators such as the SDGs. As an example, there remains considerable uncertainty about levels and age patterns of mortality and the cause of death structure.34 Investments in high-quality vital registration systems and other related data collection systems, from censuses and household surveys to health management information systems, are crucial to the proper monitoring of progress towards the SDGs.

Our GBD collaboration aims to address several of the limitations noted above in future reporting of the health-related SDGs on an annual cycle. As noted, we will also leverage work that is underway to forecast country-specifi c disease burden, which will additionally provide information on the future trajectory of health-related SDG indicators based on historical trends and provide an explicit way to understand how those trajectories could be changed with diff erent policy adoption. We will also address, in a staged manner, the absence of measures of geographical and socioeconomic inequality in the health-related SDG indicators.

ConclusionsThe measurement of 33 health-related SDG indicators presented here is the product of an extensive, open collaboration that represents many countries across a broad range of development. We invite others to join in this eff ort to produce an independent, robust basis for monitoring and assessing progress towards the SDGs. Independent measurement is a crucial component of accountability, but it is not the only component. These results should ideally be used as the basis for review and action at the country level. We hope that this collaboration is a major contribution to creating a culture of accountability for the SDGs. Other actors, especially governments, civil society organisations, donors, and global development institutions, need to participate in the process of using this information to enhance accountability through open and transparent review and action.

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GBD 2015 SDG CollaboratorsStephen S Lim, Kate Allen, Zulfi qar A Bhutta, Lalit Dandona, Mohammad H Forouzanfar, Nancy Fullman, Peter W Gething, Ellen M Goldberg, Simon I Hay, Mollie Holmberg, Yohannes Kinfu, Michael J Kutz, Heidi J Larson, Xiaofeng Liang, Alan D Lopez, Rafael Lozano, Claire R McNellan, Ali H Mokdad, Meghan D Mooney, Mohsen Naghavi, Helen E Olsen, David M Pigott, Joshua A Salomon, Theo Vos, Haidong Wang, Amanuel Alemu Abajobir*, Kalkidan Hassen Abate*, Cristiana Abbafati*, Kaja M Abbas*, Foad Abd-Allah*, Abdishakur M Abdulle*, Biju Abraham*, Ibrahim Abubakar*, Laith J Abu-Raddad*, Niveen M E Abu-Rmeileh*, Gebre Yitayih Abyu*, Tom Achoki*, Akindele Olupelumi Adebiyi*, Isaac Akinkunmi Adedeji*, Kossivi Agbelenko Afanvi*, Ashkan Afshin*, Arnav Agarwal*, Anurag Agrawal*, Aliasghar Ahmad Kiadaliri*, Hamid Ahmadieh*, Kedir Yimam Ahmed*, Ali Shafqat Akanda*, Rufus Olusola Akinyemi*, Tomi F Akinyemiju*, Nadia Akseer*, Ziyad Al-Aly*, Khurshid Alam*, Uzma Alam*, Deena Alasfoor*, Fadia S AlBuhairan*, Saleh Fahed Aldhahri*, Robert William Aldridge*, Zewdie Aderaw Alemu*, Raghib Ali*, Ala’a Alkerwi*, Mohammad AB Alkhateeb*, François Alla*, Peter Allebeck*, Christine Allen*, Rajaa Al-Raddadi*, Khalid A Altirkawi*, Elena Alvarez Martin*, Nelson Alvis-Guzman*, Azmeraw T Amare*, Alemayehu Amberbir*, Adeladza Kofi Amegah*, Heresh Amini*, Walid Ammar*, Stephen Marc Amrock*, Hjalte H Andersen*, Benjamin O Anderson*, Gregory M Anderson*, Carl Abelardo T Antonio*, Palwasha Anwari*, Johan Ärnlöv*, Al Artaman*, Hamid Asayesh*, Rana Jawad Asghar*, Suleman Atique*, Euripide Frinel G Arthur Avokpaho*, Ashish Awasthi*, Beatriz Paulina Ayala Quintanilla*, Peter Azzopardi*, Umar Bacha*, Alaa Badawi*, Kalpana Balakrishnan*, Amitava Banerjee*, Aleksandra Barac*, Ryan Barber*, Suzanne L Barker-Collo*, Till Bärnighausen*, Lope H Barrero*, Tonatiuh Barrientos-Gutierrez*, Sanjay Basu*, Tigist Assefa Bayou*, Shahrzad Bazargan-Hejazi*, Justin Beardsley*, Neeraj Bedi*, Ettore Beghi*, Yannick Béjot*, Michelle L Bell*, Aminu K Bello*, Derrick A Bennett*, Isabela M Bensenor*, Habib Benzian*, Adugnaw Berhane*, Eduardo Bernabé*, Oscar Alberto Bernal*, Balem Demtsu Betsu*, Addisu Shunu Beyene*, Neeraj Bhala*, Samir Bhatt*, Sibhatu Biadgilign*, Kelly A Bienhoff *, Boris Bikbov*, Agnes Binagwaho*, Donal Bisanzio*, Espen Bjertness*, Jed Blore*, Rupert R A Bourne*, Michael Brainin*, Michael Brauer*, Alexandra Brazinova*, Nicholas J K Breitborde*, David M Broday*, Traolach S Brugha*, Rachelle Buchbinder*, Zahid A Butt*, Leah E Cahill*, Ismael Ricardo Campos-Nonato*, Julio Cesar Campuzano*, Hélène Carabin*, Rosario Cárdenas*, Juan Jesus Carrero*, Austin Carter*, Daniel Casey*, Valeria Caso*, Carlos A Castañeda-Orjuela*, Jacqueline Castillo Rivas*, Ferrán Catalá-López*, Fiorella Cavalleri*, Pedro Cecílio*, Hsing-Yi Chang*, Jung-Chen Chang*, Fiona J Charlson*, Xuan Che*, Alan Zian Chen*, Peggy Pei-Chia Chiang*, Mirriam Chibalabala*, Vesper Hichilombwe Chisumpa*, Jee-Young Jasmine Choi*, Rajiv Chowdhury*, Hanne Christensen*, Liliana G Ciobanu*, Massimo Cirillo*, Matthew M Coates*, Megan Coggeshall*, Aaron J Cohen*, Graham S Cooke*, Cyrus Cooper*, Leslie Trumbull Cooper*, Benjamin C Cowie*, John A Crump*, Solomon Abrha Damtew*, Rakhi Dandona*, Paul I Dargan*, José das Neves*, Adrian C Davis*, Kairat Davletov*, E Filipa de Castro*, Diego De Leo*, Louisa Degenhardt*, Liana C Del Gobbo*, Kebede Deribe*, Sarah Derrett*, Don C Des Jarlais*, Aniruddha Deshpande*, Gabrielle A deVeber*, Subhojit Dey*, Samath D Dharmaratne*, Preet K Dhillon*, Eric L Ding*, E Ray Dorsey*, Kerrie E Doyle*, Tim R Driscoll*, Leilei Duan*, Manisha Dubey*, Bruce Bartholow Duncan*, Hedyeh Ebrahimi*, Aman Yesuf Endries*, Sergey Petrovich Ermakov*, Holly E Erskine*, Babak Eshrati*, Alireza Esteghamati*, Saman Fahimi*, Talha A Farid*, Carla Sofi a e Sa Farinha*, André Faro*, Maryam S Farvid*, Farshad Farzadfar*, Valery L Feigin*, Manuela Mendonca Felicio*, Seyed-Mohammad Fereshtehnejad*, Jeff erson G Fernandes*, Joao C Fernandes*, Alize J Ferrari*, Florian Fischer*, Joseph R A Fitchett*, Christina Fitzmaurice*, Nataliya Foigt*, Kyle Foreman*, F Gerry R Fowkes*, Elisabeth Barboza Franca*,

Richard C Franklin*, Maya Fraser*, Joseph Friedman*, Joseph Frostad*, Thomas Fürst*, Belinda Gabbe*, Alberto L Garcia-Basteiro*, Teshome Gebre*, Tsegaye Tewelde Gebrehiwot*, Amanuel Tesfay Gebremedhin*, Alemseged Aregay Gebru*, Bradford D Gessner*, Richard F Gillum*, Ibrahim Abdelmageem Mohamed Ginawi*, Ababi Zergaw Giref*, Maurice Giroud*, Melkamu Dedefo Gishu*, William Godwin*, Philimon Gona*, Amador Goodridge*, Sameer Vali Gopalani*, Carolyn C Gotay*, Atsushi Goto*, Hebe N Gouda*, Nicholas Graetz*, Karen Fern Greenwell*, Max Griswold*, Yuming Guo*, Rahul Gupta*, Rajeev Gupta*, Vipin Gupta*, Reyna A Gutiérrez*, Bishal Gyawali*, Juanita A Haagsma*, Annie Haakenstad*, Nima Hafezi-Nejad*, Demewoz Haile*, Gessessew Bugssa Hailu*, Yara A Halasa*, Randah Ribhi Hamadeh*, Samer Hamidi*, Mouhanad Hammami*, Graeme J Hankey*, Hilda L Harb*, Josep Maria Haro*, Mohammad Sadegh Hassanvand*, Rasmus Havmoeller*, Ileana Beatriz Heredia-Pi*, Hans W Hoek*, Masako Horino*, Nobuyuki Horita*, H Dean Hosgood*, Damian G Hoy*, Aung Soe Htet*, Guoqing Hu*, Hsiang Huang*, Kim Moesgaard Iburg*, Bulat T Idrisov*, Manami Inoue*, Farhad Islami*, Troy A Jacobs*, Kathryn H Jacobsen*, Nader Jahanmehr*, Mihajlo B Jakovljevic*, Peter James*, Henrica A F M Jansen*, Mehdi Javanbakht*, Achala Upendra Jayatilleke*, Sun Ha Jee*, Panniyammakal Jeemon*, Vivekanand Jha*, Ying Jiang*, Tariku Jibat*, Ye Jin*, Jost B Jonas*, Zubair Kabir*, Yogeshwar Kalkonde*, Ritul Kamal*, Haidong Kan*, Amit Kandel*, André Karch*, Corine Kakizi Karema*, Chante Karimkhani*, Palitha Karunapema*, Amir Kasaeian*, Nicholas J Kassebaum*, Anil Kaul*, Norito Kawakami*, Jeanne Françoise Kayibanda*, Peter Njenga Keiyoro*, Laura Kemmer*, Andrew Haddon Kemp*, Andre Pascal Kengne*, Andre Keren*, Chandrasekharan Nair Kesavachandran*, Yousef Saleh Khader*, Abdur Rahman Khan*, Ejaz Ahmad Khan*, Gulfaraz Khan*, Young-Ho Khang*, Tawfi k Ahmed Muthafer Khoja*, Ardeshir Khosravi*, Jagdish Khubchandani*, Christian Kieling*, Cho-il Kim*, Daniel Kim*, Sungroul Kim*, Yun Jin Kim*, Ruth W Kimokoti*, Niranjan Kissoon*, Miia Kivipelto*, Luke D Knibbs*, Yoshihiro Kokubo*, Dhaval Kolte*, Soewarta Kosen*, Georgios A Kotsakis*, Parvaiz A Koul*, Ai Koyanagi*, Michael Kravchenko*, Hans Krueger*, Barthelemy Kuate Defo*, Ricardo S Kuchenbecker*, Ernst J Kuipers*, Xie Rachel Kulikoff *, Veena S Kulkarni*, G Anil Kumar*, Gene F Kwan*, Hmwe H Kyu*, Aparna Lal*, Dharmesh Kumar Lal*, Ratilal Lalloo*, Hilton Lam*, Qing Lan*, Sinead M Langan*, Anders Larsson*, Dennis Odai Laryea*, Asma Abdul Latif*, Janet L Leasher*, James Leigh*, Mall Leinsalu*, Janni Leung*, Ricky Leung*, Miriam Levi*, Yichong Li*, Yongmei Li*, Margaret Lind*, Shai Linn*, Steven E Lipshultz*, Patrick Y Liu*, Shiwei Liu*, Yang Liu*, Belinda K Lloyd*, Loon-Tzian Lo*, Giancarlo Logroscino*, Paulo A Lotufo*, Robyn M Lucas*, Raimundas Lunevicius*, Mohammed Magdy Abd El Razek*, Carlos Magis-Rodriguez*, Mahdi Mahdavi*, Marek Majdan*, Azeem Majeed*, Reza Malekzadeh*, Deborah Carvalho Malta*, Chabila C Mapoma*, David Joel Margolis*, Randall V Martin*, Jose Martinez-Raga*, Felix Masiye*, Amanda J Mason-Jones*, João Massano*, Richard Matzopoulos*, Bongani M Mayosi*, John J McGrath*, Martin McKee*, Peter A Meaney*, Alem Mehari*, Alemayehu B Mekonnen*, Yohannes Adama Melaku*, Peter Memiah*, Ziad A Memish*, Walter Mendoza*, Gert B M Mensink*, Atte Meretoja*, Tuomo J Meretoja*, Yonatan Moges Mesfi n*, Francis Apolinary Mhimbira*, Renata Micha*, Ted R Miller*, Edward J Mills*, Mojde Mirarefi n*, Awoke Misganaw*, Philip B Mitchell*, Charles N Mock*, Alireza Mohammadi*, Shafi u Mohammed*, Lorenzo Monasta*, Jonathan de la Cruz Monis*, Julio Cesar Montañez Hernandez*, Marcella Montico*, Maziar Moradi-Lakeh*, Lidia Morawska*, Rintaro Mori*, Ulrich O Mueller*, Michele E Murdoch*, Brighton Murimira*, Joseph Murray*, Gudlavalleti Venkata Satyanarayana Murthy*, Srinivas Murthy*, Kamarul Imran Musa*, Jean B Nachega*, Gabriele Nagel*, Kovin S Naidoo*, Luigi Naldi*, Vinay Nangia*, Bruce Neal*, Chakib Nejjari*, Charles R Newton*, John N Newton*, Frida Namnyak Ngalesoni*, Peter Nguhiu*, Grant Nguyen*,

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Quyen Le Nguyen*, Muhammad Imran Nisar*, Patrick Martial Nkamedjie Pete*, Sandra Nolte*, Marika Nomura*, Ole F Norheim*, Bo Norrving*, Carla Makhlouf Obermeyer*, Felix Akpojene Ogbo*, In-Hwan Oh*, Olanrewaju Oladimeji*, Pedro R Olivares*, Bolajoko Olubukunola Olusanya*, Jacob Olusegun Olusanya*, John Nelson Opio*, Eyal Oren*, Alberto Ortiz*, Richard H Osborne*, Erika Ota*, Mayowa O Owolabi*, Mahesh PA*, Eun-Kee Park*, Hye-Youn Park*, Charles D Parry*, Mahboubeh Parsaeian*, Tejas Patel*, Vikram Patel*, Angel J Paternina Caicedo*, Snehal T Patil*, Scott B Patten*, George C Patton*, Deepak Paudel*, João Mário Pedro*, David M Pereira*, Norberto Perico*, Konrad Pesudovs*, Max Petzold*, Michael Robert Phillips*, Frédéric B Piel*, Julian David Pillay*, Christine Pinho*, Farhad Pishgar*, Suzanne Polinder*, Richie G Poulton*, Farshad Pourmalek*, Mostafa Qorbani*, Rynaz H S Rabiee*, Amir Radfar*, Vafa Rahimi-Movaghar*, Mahfuzar Rahman*, Mohammad Hifz Ur Rahman*, Sajjad Ur Rahman*, Rajesh Kumar Rai*, Sasa Rajsic*, Murugesan Raju*, Usha Ram*, Saleem M Rana*, Chhabi Lal Ranabhat*, Kavitha Ranganathan*, Puja C Rao*, Amany H Refaat*, Marissa B Reitsma*, Giuseppe Remuzzi*, Serge Resnikoff *, Antonio L Ribeiro*, Maria Jesus Rios Blancas*, Hirbo Shore Roba*, Bayard Roberts*, Alina Rodriguez*, David Rojas-Rueda*, Luca Ronfani*, Gholamreza Roshandel*, Gregory A Roth*, Dietrich Rothenbacher*, Ambuj Roy*, Nobhojit Roy*, Ben Benasco Sackey*, Rajesh Sagar*, Muhammad Muhammad Saleh*, Juan R Sanabria*, Damian F Santomauro*, Itamar S Santos*, Rodrigo Sarmiento-Suarez*, Benn Sartorius*, Maheswar Satpathy*, Miloje Savic*, Monika Sawhney*, Susan M Sawyer*, Josef Schmidhuber*, Maria Inês Schmidt*, Ione J C Schneider*, Aletta E Schutte*, David C Schwebel*, Soraya Seedat*, Sadaf G Sepanlou*, Edson E Servan-Mori*, Katya Shackelford*, Amira Shaheen*, Masood Ali Shaikh*, Teresa Shamah Levy*, Rajesh Sharma*, Jun She*, Sara Sheikhbahaei*, Jiabin Shen*, Kevin N Sheth*, Muki Shey*, Peilin Shi*, Kenji Shibuya*, Mika Shigematsu*, Min-Jeong Shin*, Rahman Shiri*, Kawkab Shishani*, Ivy Shiue*, Inga Dora Sigfusdottir*, Naris Silpakit*, Diego Augusto Santos Silva*, Jonathan I Silverberg*, Edgar P Simard*, Shireen Sindi*, Abhishek Singh*, Gitanjali M Singh*, Jasvinder A Singh*, Om Prakash Singh*, Prashant Kumar Singh*, Vegard Skirbekk*, Amber Sligar*, Samir Soneji*, Kjetil Søreide*, Reed J D Sorensen*, Joan B Soriano*, Sergey Soshnikov*, Luciano A Sposato*, Chandrashekhar T Sreeramareddy*, Hans-Christian Stahl*, Jeff rey D Stanaway*, Vasiliki Stathopoulou*, Nadine Steckling*, Nicholas Steel*, Dan J Stein*, Caitlyn Steiner*, Heidi Stöckl*, Saverio Stranges*, Mark Strong*, Jiandong Sun*, Bruno F Sunguya*, Patrick Sur*, Soumya Swaminathan*, Bryan L Sykes*, Cassandra E I Szoeke*, Rafael Tabarés-Seisdedos*, Karen M Tabb*, Roberto Tchio Talongwa*, Mohammed Rasoul Tarawneh*, Mohammad Tavakkoli*, Bineyam Taye*, Hugh R Taylor*, Bemnet Amare Tedla*, Worku Tefera*, Teketo Kassaw Tegegne*, Dejen Yemane Tekle*, Girma Temam Shifa*, Abdullah Sulieman Terkawi*, Gizachew Assefa Tessema*, J S Thakur*, Alan J Thomson*, Andrew L Thorne-Lyman*, Amanda G Thrift*, George D Thurston*, Taavi Tillmann*, Ruoyan Tobe-Gai*, Marcello Tonelli*, Roman Topor-Madry*, Fotis Topouzis*, Bach Xuan Tran*, Zacharie Tsala Dimbuene*, Abera Kenay Tura*, Emin Murat Tuzcu*, Stefanos Tyrovolas*, Kingsley Nnanna Ukwaja*, Eduardo A Undurraga*, Chigozie Jesse Uneke*, Olalekan A Uthman*, Aaron van Donkelaar*, Yuri Y Varakin*, Tommi Vasankari*, Ana Maria Nogales Vasconcelos*, J Lennert Veerman*, Narayanaswamy Venketasubramanian*, Raj Kumar Verma*, Francesco S Violante*, Vasiliy Victorovich Vlassov*, Patricia Volkow*, Stein Emil Vollset*, Gregory R Wagner*, Mitchell T Wallin*, Linhong Wang*, Valentine Wanga*, David A Watkins*, Scott Weichenthal*, Elisabete Weiderpass*, Robert G Weintraub*, Daniel J Weiss*, Andrea Werdecker*, Ronny Westerman*, Harvey A Whiteford*, James D Wilkinson*, Charles Shey Wiysonge*, Charles D A Wolfe*, Ingrid Wolfe*, Sungho Won*, Anthony D Woolf*, Shimelash Bitew Workie*, Mamo Wubshet*, Gelin Xu*, Ajit Kumar Yadav*, Bereket Yakob*, Ayalnesh Zemene Yalew*, Lijing L Yan*, Yuichiro Yano*, Mehdi Yaseri*, Pengpeng Ye*, Paul Yip*,

Naohiro Yonemoto*, Seok-Jun Yoon*, Mustafa Z Younis*, Chuanhua Yu*, Zoubida Zaidi*, Maysaa El Sayed Zaki*, Carlos Zambrana-Torrelio*, Tomas Zapata*, Elias Asfaw Zegeye*, Yi Zhao*, Maigeng Zhou*, Sanjay Zodpey*, David Zonies*, Christopher J L Murray†. *Authors listed alphabetically. †Corresponding author.

Affi liationsInstitute for Health Metrics and Evaluation (Prof S S Lim PhD, K Allen BA, Prof L Dandona MD, M H Forouzanfar MD, N Fullman MPH, E M Goldberg BSc, Prof S I Hay DSc, M Holmberg BS, M J Kutz BS, H J Larson PhD, Prof A D Lopez PhD, C R McNellan BA, Prof A H Mokdad PhD, M D Mooney BS, Prof M Naghavi PhD, H E Olsen MA, D M Pigott DPhil, Prof T Vos PhD, H Wang PhD, T Achoki MD, A Afshin MD, C Allen BA, G M Anderson MSEE, R Barber BS, K A Bienhoff MA, J Blore PhD, Prof M Brauer ScD, A Carter BS, D Casey BA, F J Charlson PhD, A Z Chen BS, M M Coates MPH, M Coggeshall BA, A J Cohen DSc, A Deshpande MPH, H E Erskine PhD, A J Ferrari PhD, C Fitzmaurice MD, K Foreman PhD, M Fraser BA, J Friedman BA, J Frostad MPH, W Godwin BS, N Graetz MPH, M Griswold MS, J A Haagsma PhD, A Haakenstad MA, N J Kassebaum MD, L Kemmer PhD, X R Kulikoff BA, H H Kyu PhD, J Leung PhD, M Lind BS, P Y Liu BA, F Masiye PhD, M Mirarefi n MPH, A Misganaw PhD, M Moradi-Lakeh MD, G Nguyen MPH, C Pinho BA, P C Rao MPH, M B Reitsma BS, G A Roth MD, D F Santomauro PhD, K Shackelford BA, N Silpakit BS, A Sligar MPH, R J D Sorensen MPH, J D Stanaway PhD, C Steiner MPH, P Sur BA, Prof S E Vollset DrPH, V Wanga MS, Prof H A Whiteford PhD, Y Zhao MS, Prof M Zhou PhD, Prof C J L Murray DPhil), School of Dentistry (G A Kotsakis DDS), Harborview Injury Prevention and Research Center (C N Mock PhD), University of Washington, Seattle, WA, USA (Prof B O Anderson MD, D A Watkins MD); Centre of Excellence in Women and Child Health (Z A Bhutta PhD), Aga Khan University, Karachi, Pakistan (M I Nisar MSc); Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON, Canada (Z A Bhutta PhD, N Akseer MSc, G A deVeber MD); Centre for Control of Chronic Conditions (P Jeemon PhD), Public Health Foundation of India, New Delhi, India (Prof L Dandona MD, R Dandona PhD, G A Kumar PhD); Department of Zoology (P W Gething PhD), Nuffi eld Department of Medicine (D Bisanzio PhD), NIHR Musculoskeletal Biomedical Research Centre (Prof C Cooper FMedSci), University of Oxford, Oxford, UK (R Ali FRCP, D A Bennett PhD, Prof V Jha DM, D J Weiss PhD); Centre for Research & Action in Public Health, Faculty of Health, University of Canberra, Canberra, ACT, Australia (Y Kinfu PhD); Department of Infectious Disease Epidemiology (H J Larson PhD), Centre for Global Mental Health (Prof V Patel PhD), London School of Hygiene and Tropical Medicine, London, UK (S M Langan PhD, Prof M McKee DSc, Prof G V S Murthy MD, B Roberts PhD, H Stöckl DPhil); National Center for Chronic and Noncommunicable Disease Control and Prevention (L Duan MD, Y Jin MS, Y Li MPH, S Liu PhD, Prof L Wang MD, P Ye MPH, Prof M Zhou PhD), Chinese Center for Disease Control and Prevention, Beijing, China (Prof X Liang MD); Melbourne School of Population and Global Health (Prof A D Lopez PhD), Department of Paediatrics (P Azzopardi MEpi), The Peter Doherty Institute for Infection and Immunity (Prof B C Cowie PhD), Department of Medicine (A Meretoja PhD), Murdoch Childrens Research Institute (Prof G C Patton MD, K Alam PhD, P Azzopardi MEpi, R G Weintraub MBBS), Department of Pediatrics (Prof S M Sawyer MD), Institute of Health and Ageing (Prof C E I Szoeke PhD), The University of Melbourne, Melbourne, VIC, Australia (K Alam PhD, Prof H R Taylor AC, R G Weintraub MBBS); National Institute of Public Health, Cuernavaca, Mexico (R Lozano MD, T Barrientos-Gutierrez PhD, I R Campos-Nonato PhD, J C Campuzano PhD, I B Heredia-Pi PhD, J C Montañez Hernandez MSc, M J Rios Blancas MPH, Prof E E Servan-Mori MSc, T Shamah Levy PhD); Department of Global Health and Population, Harvard T H Chan School of Public Health (Prof J A Salomon PhD), Department of Global Health and Social Medicine, Harvard Medical School (Prof A Binagwaho PhD), Department of Epidemiology (P James ScD) Harvard T H Chan School of Public Health (Prof T Bärnighausen MD, L E Cahill PhD,

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I R Campos-Nonato PhD, E L Ding ScD, M S Farvid PhD, A Haakenstad MA, G R Wagner MD), Department of Nutrition, Harvard T H Chan School of Public Health (A L Thorne-Lyman ScD), Channing Division of Network Medicine, Brigham & Women’s Hospital, Harvard Medical School (P James ScD), Harvard University, Boston, MA, USA (J R A Fitchett MD); School of Public Health (A A Abajobir MPH, F J Charlson PhD, H E Erskine PhD, A J Ferrari PhD, L D Knibbs PhD, J Leung PhD, D F Santomauro PhD, J L Veerman PhD, Prof H A Whiteford PhD), School of Dentistry (Prof R Lalloo PhD), University of Queensland, Brisbane, QLD, Australia (H N Gouda PhD, Y Guo PhD, Prof J J McGrath MD); Jimma University, Jimma, Ethiopia (K H Abate MS, T T Gebrehiwot MPH, A T Gebremedhin MPH); La Sapienza, University of Rome, Rome, Italy (C Abbafati PhD); Virginia Tech, Blacksburg, VA, USA (Prof K M Abbas PhD); Department of Neurology, Cairo University, Cairo, Egypt (Prof F Abd-Allah MD); New York University Abu Dhabi, Abu Dhabi, United Arab Emirates (A M Abdulle PhD); NMSM Government College Kalpetta, Kerala, India (Prof B Abraham MPhil); Institute for Global Health (Prof I Abubakar PhD, R W Aldridge PhD), Centre for Public Health Data Science, Institute of Health Informatics (R W Aldridge PhD), Farr Institute of Health Informatics Research (R W Aldridge PhD, A Banerjee DPhil), Department of Epidemiology and Public Health (H Benzian PhD, T Tillmann MSc), University College London, London, UK; Infectious Disease Epidemiology Group, Weill Cornell Medical College in Qatar, Doha, Qatar (L J Abu-Raddad PhD); Institute of Community and Public Health, Birzeit University, Ramallah, Palestine (N M Abu-Rmeileh PhD); School of Public Health (Y A Melaku MPH), Mekelle University, Mekelle, Ethiopia (Prof G Y Abyu MS, T A Bayou BS, B D Betsu MS, A A Gebru MPH, G B Hailu MSc, D Y Tekle MS, A Z Yalew MS); College of Medicine (A O Adebiyi MD), Department of Medicine (M O Owolabi Dr Med), University of Ibadan, Ibadan, Nigeria (R O Akinyemi PhD); University College Hospital, Ibadan, Nigeria (A O Adebiyi MD); Olabisi Onabanjo University, Ago-Iwoye, Nigeria (I A Adedeji MS); Direction du District Sanitaire de Haho, Notse, Togo (K A Afanvi MD); Faculte des Sciences de Sante, Universite de Lome, Lome, Togo (K A Afanvi MD); Friedman School of Nutrition Science and Policy (A Afshin MD, R Micha PhD), Tufts University, Boston, MA, USA (P Shi PhD, G M Singh PhD); Dalla Lana School of Public Health (N Akseer MSc), Department of Nutritional Sciences, Faculty of Medicine (A Badawi PhD), University of Toronto, Toronto, ON, Canada (A Agarwal BHSc); McMaster University, Hamilton, ON, Canada (A Agarwal BHSc); CSIR Institute of Genomics and Integrative Biology, Delhi, India (A Agrawal PhD); Department of Internal Medicine, Baylor College of Medicine, Houston, TX, USA (A Agrawal PhD); Department of Clinical Sciences Lund, Orthopedics, Clinical Epidemiology Unit (A Ahmad Kiadaliri PhD), Skane University Hospital, Department of Clinical Sciences Lund (Prof B Norrving PhD), Lund University, Lund, Sweden; Health Services Management Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran (A Ahmad Kiadaliri PhD); Ophthalmic Research Center (H Ahmadieh MD, M Yaseri PhD), School of Public Health (N Jahanmehr PhD), Shahid Beheshti University of Medical Sciences, Tehran, Iran; Department of Ophthalmology, Labbafi nejad Medical Center, Tehran, Iran (H Ahmadieh MD); Debre Markos University, Debre Markos, Ethiopia (K Y Ahmed MPH, Z A Alemu MPH, T K Tegegne MPH); University of Rhode Island, Kingston, RI, USA (A S Akanda PhD); Newcastle University, Newcastle upon Tyne, UK (R O Akinyemi PhD); Department of Epidemiology (T F Akinyemiju PhD), University of Alabama at Birmingham, Birmingham, AL, USA (D C Schwebel PhD, J A Singh MD); Washington University in Saint Louis, St Louis, MO, USA (Z Al-Aly MD); Sydney School of Public Health (Prof T R Driscoll PhD), The University of Sydney, Sydney, NSW, Australia (K Alam PhD, J Leigh PhD, A B Mekonnen MS, Prof B Neal PhD); International Center for Humanitarian Aff airs, Nairobi, Kenya (U Alam PhD); Ministry of Health, Al Khuwair, Oman (D Alasfoor MSc); King Abdullah Specialized Children’s Hospital, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia (F S AlBuhairan MD); King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (F S AlBuhairan MD); King Khalid University Hospital (M A Alkhateeb BA), King Saud University, Riyadh, Saudi Arabia

(S F Aldhahri MD, K A Altirkawi MD); Department of Anesthesiology (A S Terkawi MD), King Fahad Medical City, Riyadh, Saudi Arabia (S F Aldhahri MD); Luxembourg Institute of Health (LIH), Strassen, Luxembourg (A Alkerwi PhD); School of Public Health, University of Lorraine, Nancy, France (Prof F Alla PhD); Department of Public Health Sciences (P Allebeck PhD, R H S Rabiee MPH, N Roy MD), Aging Research Center (Prof M Kivipelto PhD), Department of Clinical Science, Intervention and Technology (Prof J J Carrero PhD), Department of Neurobiology, Care Sciences and Society (NVS) (S M Fereshtehnejad PhD), Department of Medical Epidemiology and Biostatistics (E Weiderpass PhD), Karolinska Institutet, Stockholm, Sweden (R Havmoeller PhD, S Sindi PhD); Ministry of Health, Jeddah, Saudi Arabia (R Al-Raddadi PhD); Government, Madrid, Spain (E Alvarez Martin PhD); Universidad de Cartagena, Cartagena, Colombia (Prof N Alvis-Guzman PhD, A J Paternina Caicedo MD); School of Medicine (A T Amare MPH, Y A Melaku MPH), University of Adelaide, Adelaide, SA, Australia (L G Ciobanu MS, G A Tessema MPH); College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia (A T Amare MPH); Dignitas International, Zomba, Malawi (A Amberbir PhD); University of Cape Coast, Cape Coast, Ghana (A K Amegah PhD); Environmental Health Research Center, Kurdistan University of Medical Sciences, Sanandaj, Iran (H Amini MSPH); Department of Epidemiology and Public Health (H Amini MSPH, T Fürst PhD), Swiss Tropical and Public Health Institute, Basel, Switzerland (C K Karema MSc); Ministry of Public Health, Beirut, Lebanon (W Ammar PhD, H L Harb MPH); Oregon Health & Science University, Portland, OR, USA (S M Amrock MD); Center for Sensory-Motor Interaction, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark (H H Andersen MSc); Department of Health Policy and Administration, College of Public Health, University of the Philippines Manila, Manila, Philippines (C A T Antonio MD); Self-employed, Kabul, Afghanistan (P Anwari MD); Department of Medical Sciences, Uppsala University, Uppsala, Sweden (Prof J Ärnlöv PhD, Prof A Larsson PhD); Dalarna University, Falun, Sweden (Prof J Ärnlöv PhD); University of Manitoba, Winnipeg, MB, Canada (A Artaman PhD); Department of Medical Emergency, School of Paramedic, Qom University of Medical Sciences, Qom, Iran (H Asayesh PhD); South Asian Public Health Forum, Islamabad, Pakistan (R J Asghar MD); Graduate Institute of Biomedical Informatics, Taipei Medical University, Taipei, Taiwan (S Atique MS); Institut de Recherche Clinique du Bénin, Cotonou, Benin Republic (E F G A Avokpaho MPH); Laboratoire d’Etudes et de Recherche-Action en Santé (LERAS Afrique), Parakou, Benin Republic (E F G A Avokpaho MPH); Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India (A Awasthi MSc); The Judith Lumley Centre for Mother, Infant and Family Health Research, La Trobe University, Melbourne, VIC, Australia (B P Ayala Quintanilla PhD); Peruvian National Institute of Health, Lima, Peru (B P Ayala Quintanilla PhD); Wardliparingga Aboriginal Research Unit, South Australian Health and Medical Research Institute, Adelaide, SA, Australia (P Azzopardi MEpi); Centre for International Health, Burnet Institute, Melbourne, VIC, Australia (P Azzopardi MEpi); School of Health Sciences, University of Management and Technology, Lahore, Pakistan (U Bacha PhD); Public Health Agency of Canada, Toronto, ON, Canada (A Badawi PhD); Department of Environmental Health Engineering, Sri Ramachandra University, Chennai, India (K Balakrishnan PhD); Faculty of Medicine, University of Belgrade, Belgrade, Serbia (A Barac PhD); School of Psychology, University of Auckland, Auckland, New Zealand (S L Barker-Collo PhD); Africa Health Research Institute, Mtubatuba, South Africa (Prof T Bärnighausen MD); Institute of Public Health, Heidelberg University, Heidelberg, Germany (Prof T Bärnighausen MD, S Mohammed PhD); Department of Industrial Engineering, School of Engineering, Pontifi cia Universidad Javeriana, Bogotá, Colombia (L H Barrero ScD); Stanford University, Stanford, CA, USA (S Basu PhD, L C Del Gobbo PhD); College of Medicine, Charles R Drew University of Medicine and Science, Los Angeles, CA, USA (Prof S Bazargan-Hejazi PhD); David Geff en School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA (Prof S Bazargan-Hejazi PhD); Kermanshah University of Medical Science, Kermanshah, Iran (Prof S Bazargan-Hejazi PhD); Oxford University, Ho Chi Minh City, Vietnam (J Beardsley MBChB);

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College of Public Health and Tropical Medicine, Jazan, Saudi Arabia (N Bedi MD); IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy (E Beghi MD); University Hospital and Medical School of Dijon, University of Burgundy, Dijon, France (Prof Y Béjot PhD); School of Medicine (K N Sheth MD), Yale University, New Haven, CT, USA (Prof M L Bell PhD); University of Alberta, Edmonton, AB, Canada (A K Bello PhD); Internal Medicine Department (Prof I S Santos PhD), University of São Paulo, São Paulo, Brazil (I M Bensenor PhD, Prof P A Lotufo DrPH); Department of Epidemiology and Health Promotion, College of Dentistry (H Benzian PhD), New York University, New York, NY, USA; Debre Berhane University, Debre Berhan, Ethiopia (A Berhane PhD); Division of Health and Social Care Research (Prof C D Wolfe MD), King’s College London, London, UK (E Bernabé PhD, I Wolfe PhD); University Andes, Bogotá, Colombia (O A Bernal PhD); College of Health and Medical Sciences (H S Roba MPH), Haramaya University, Harar, Ethiopia (A S Beyene MPH, Y M Mesfi n MPH); Queen Elizabeth Hospital Birmingham, Birmingham, UK (N Bhala DPhil); University of Otago Medical School, Wellington, New Zealand (N Bhala DPhil); Imperial College, London, UK (S Bhatt DPhil); Independent Public Health Consultants, Addis Ababa, Ethiopia (S Biadgilign MPH); Department of Nephrology Issues of Transplanted Kidney, Academician V I Shumakov Federal Research Center of Transplantology and Artifi cial Organs, Moscow, Russia (B Bikbov MD); Department of Pediatrics & The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine (Prof A Binagwaho PhD), Dartmouth College, Hanover, NH, USA (S Soneji PhD); The University of Global Health Equity, Kigali, Rwanda (Prof A Binagwaho PhD); Department of Community Medicine (Prof E Bjertness PhD), University of Oslo, Oslo, Norway (A S Htet MPhil); Vision & Eye Research Unit, Anglia Ruskin University, Cambridge, UK (Prof R R A Bourne FRCOphth); Danube-University Krems, Krems, Austria (Prof M Brainin PhD); School of Population and Public Health (H Krueger PhD), University of British Columbia, Vancouver, BC, Canada (Prof M Brauer ScD, C C Gotay PhD, Prof N Kissoon MD, S Murthy MD, F Pourmalek PhD); Faculty of Health Sciences and Social Work, Department of Public Health, Trnava University, Trnava, Slovakia (A Brazinova PhD, M Majdan PhD); International Neurotrauma Research Organization, Vienna, Austria (A Brazinova PhD); College of Medicine (J Shen PhD), The Ohio State University, Columbus, OH, USA (Prof N J K Breitborde PhD); Technion, Haifa, Israel (Prof D M Broday DSc); University of Leicester, Leicester, UK (Prof T S Brugha MD); Monash Department of Clinical Epidemiology, Cabrini Institute, Melbourne, VIC, Australia (Prof R Buchbinder PhD); Department of Epidemiology and Preventive Medicine (Prof R Buchbinder PhD), School of Public Health and Preventive Medicine (Prof B Gabbe PhD), Department of Medicine, School of Clinical Sciences at Monash Health (Prof A G Thrift PhD), Monash University, Melbourne, VIC, Australia; Al Shifa Trust Eye Hospital, Rawalpindi, Pakistan (Z A Butt PhD); Department of Physics and Atmospheric Science (A van Donkelaar PhD), Dalhousie University, Halifax, NS, Canada (L E Cahill PhD, Prof R V Martin PhD); Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA (H Carabin PhD); Metropolitan Autonomous University, Mexico City, Mexico (R Cárdenas ScD); Stroke Unit, University of Perugia, Perugia, Italy (V Caso MD); Colombian National Health Observatory, Instituto Nacional de Salud, Bogotá, Colombia (C A Castañeda-Orjuela MSc); Epidemiology and Public Health Evaluation Group, Public Health Department, Universidad Nacional de Colombia, Bogotá, Colombia (C A Castañeda-Orjuela MSc); Caja Costarricense de Seguro Social, San Jose, Costa Rica (Prof J Castillo Rivas MPH); Universidad de Costa Rica, San Pedro, Montes de Oca, Costa Rica (Prof J Castillo Rivas MPH); Department of Medicine, University of Valencia/INCLIVA Health Research Institute and CIBERSAM, Valencia, Spain (F Catalá-López PhD); Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada (F Catalá-López PhD); Faculty of Medicine, University of the Republic, Montevideo, Uruguay (F Cavalleri BS); i3S - Instituto de Investigação e Inovação em Saúde (P Cecílio MS, J das Neves PhD); Pharmacy Faculty (P Cecílio MS), INEB - Instituto de Engenharia Biomédica (J das Neves PhD), Faculty of Medicine (J Massano MD), EPIUnit - Institute of Public Health

(J M Pedro MS), University of Porto, Porto, Portugal; National Health Research Institutes, Zhunan Town, Taiwan (Prof H Chang DrPH); National Yang-Ming University, Taipei, Taiwan (Prof H Chang DrPH); School of Nursing, College of Medicine, National Taiwan University, Taipei, Taiwan (Prof J Chang PhD); Queensland Centre for Mental Health Research, Brisbane, QLD, Australia (F J Charlson PhD, H E Erskine PhD, A J Ferrari PhD, J Leung PhD, D F Santomauro PhD, Prof H A Whiteford PhD); African Centre for Statistics, United Nations Economic Commission for Africa, Addis Ababa, Ethiopia (X Che PhD); Clinical Governance Unit, Gold Coast Health, Southport, QLD, Australia (P P Chiang PhD); Crowd Watch Africa, Lusaka, Zambia (M Chibalabala BS); University of Zambia, Lusaka, Zambia (V H Chisumpa MPhil, C C Mapoma PhD, F Masiye PhD); University of Witwatersrand, Johannesburg, South Africa (V H Chisumpa MPhil); Seoul National University Medical Library, Seoul, South Korea (J J Choi PhD); Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK (R Chowdhury PhD); Bispebjerg University Hospital, Copenhagen, Denmark (Prof H Christensen DMSCi); University of Salerno, Baronissi, Italy (Prof M Cirillo MD); Health Eff ects Institute, Boston, MA, USA (A J Cohen DSc); Department of Infectious Disease Epidemiology (T Fürst PhD), Department of Epidemiology and Biostatistics (F B Piel PhD), Department of Epidemiology and Biostatistics, School of Public Health (Prof A Rodriguez PhD), Imperial College London, London, UK (G S Cooke DPhil, Prof A Majeed MD, Prof B Neal PhD); MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK (Prof C Cooper FMedSci); NIHR Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK (Prof C Cooper FMedSci); Mayo Clinic, Jacksonville, FL, USA (L T Cooper MD); WHO Collaborating Centre for Viral Hepatitis, Victorian Infectious Diseases Reference Laboratory, Melbourne, VIC, Australia (Prof B C Cowie PhD); Centre for International Health, Dunedin School of Medicine (Prof J A Crump MD), Injury Prevention Research Unit, Department of Preventive and Social Medicine, Dunedin School of Medicine (Prof S Derrett PhD), University of Otago, Dunedin, New Zealand (Prof R G Poulton PhD); Wolaita Sodo University, Wolaita Sodo, Ethiopia (S A Damtew MPH, S B Workie MPH); School of Public Health (K Deribe MPH), College of Health Sciences, School of Public Health (W Tefera MPH), Addis Ababa University, Addis Ababa, Ethiopia (S A Damtew MPH, A Z Giref PhD, D Haile MPH, G Temam Shifa MPH); Guy’s and St Thomas’ NHS Foundation Trust, London, UK (Prof P I Dargan FRCP); Public Health England, London, UK (Prof A C Davis PhD, Prof J N Newton FRCP, Prof N Steel PhD); School of Public Health, Kazakh National Medical University, Almaty, Kazakhstan (K Davletov PhD); National Institute of Public Health, Mexico City, Mexico (E F de Castro PhD); Griffi th University, Brisbane, QLD, Australia (Prof D De Leo DSc); National Drug and Alcohol Research Centre (Prof L Degenhardt PhD), Brien Holden Vision Institute (Prof S Resnikoff MD), School of Optometry and Vision Science (Prof S Resnikoff MD), University of New South Wales, Sydney, NSW, Australia (Prof P B Mitchell MD); Brighton and Sussex Medical School, Brighton, UK (K Deribe MPH); Mount Sinai Beth Israel, New York, NY, USA (Prof D C Des Jarlais PhD); Icahn School of Medicine at Mount Sinai, New York, NY, USA (Prof D C Des Jarlais PhD); Indian Institute of Public Health-Delhi (S Dey PhD, Prof G V S Murthy MD), Centre for Control of Chronic Conditions (P Jeemon PhD), Centre for Chronic Conditions and Injuries (Prof V Patel PhD), Public Health Foundation of India, Gurgaon, India (P K Dhillon PhD, D K Lal MD, Prof S Zodpey PhD); Department of Community Medicine, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka (S D Dharmaratne MD); University of Rochester Medical Center, Rochester, NY, USA (E R Dorsey MD); RMIT University, Bundoora, VIC, Australia (Prof K E Doyle PhD); The University of Sydney, Camperdown, NSW, Australia (Prof A H Kemp PhD); International Institute for Population Sciences, Mumbai, India (M Dubey MPhil, M H U Rahman MPhil, Prof U Ram PhD, A Singh PhD, R K Verma MPhil, A K Yadav MPhil); Federal University of Rio Grande do Sul, Porto Alegre, Brazil (B B Duncan PhD, C Kieling MD, Prof M I Schmidt MD); University of North Carolina, Chapel Hill, NC, USA (B B Duncan PhD); Non-Communicable Diseases Research Center,

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Endocrinology and Metabolism Population Sciences Institute (H Ebrahimi MD, Prof A Esteghamati MD, F Farzadfar MD, N Hafezi-Nejad MD, A Kasaeian PhD, M Parsaeian PhD, F Pishgar MD, S Sheikhbahaei MD), Liver and Pancreaticobiliary Diseases Research Center, Digestive Disease Research Institute, Shariati Hospital (H Ebrahimi MD), Digestive Diseases Research Institute (S Fahimi PhD, Prof R Malekzadeh MD, G Roshandel PhD, S G Sepanlou PhD), Center for Air Pollution Research, Institute for Environmental Research (M S Hassanvand PhD), Hematology-Oncology and Stem Cell Transplantation Research Center (A Kasaeian PhD), Non-Communicable Diseases Research Center (A Khosravi PhD), Department of Epidemiology and Biostatistics, School of Public Health (M Parsaeian PhD), Uro-Oncology Research Center (F Pishgar MD), Sina Trauma and Surgery Research Center (Prof V Rahimi-Movaghar MD), Tehran University of Medical Sciences, Tehran, Iran (M Yaseri PhD); Arba Minch University, Arba Minch, Ethiopia (A Y Endries MPH, G Temam Shifa MPH); The Institute of Social and Economic Studies of Population, Russian Academy of Sciences, Moscow, Russia (Prof S P Ermakov DSc); Federal Research Institute for Health Organization and Informatics, Ministry of Health of the Russian Federation, Moscow, Russia (Prof S P Ermakov DSc, S Soshnikov PhD); Ministry of Health and Medical Education, Tehran, Iran (B Eshrati PhD); Arak University of Medical Sciences, Arak, Iran (B Eshrati PhD); University of Louisville, Louisville, KY, USA (T A Farid MD, A R Khan MD); DGS Directorate General of Health, Lisboa, Portugal (C S E S Farinha MSc); Universidade Aberta, Lisboa, Portugal (C S E S Farinha MSc); Federal University of Sergipe, Aracaju, Brazil (Prof A Faro PhD); Harvard/MGH Center on Genomics, Vulnerable Populations, and Health Disparities, Mongan Institute for Health Policy, Massachusetts General Hospital, Boston, MA, USA (M S Farvid PhD); National Institute for Stroke and Applied Neurosciences, Auckland University of Technology, Auckland, New Zealand (V L Feigin PhD); ARS Norte, I P, Departamento Saúde Pública, Porto, Portugal (M M Felicio MD); Institute of Education and Sciences, German Hospital Oswaldo Cruz, São Paulo, Brazil (Prof J G Fernandes PhD); Centre for Experimental Medicine & Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK (J C Fernandes PhD); Bielefeld University, Bielefeld, Germany (F Fischer MPH); Institute of Gerontology, Academy of Medical Science, Kyiv, Ukraine (N Foigt PhD); Alzheimer Scotland Dementia Research Centre (I Shiue PhD), University of Edinburgh, Edinburgh, UK (Prof F G R Fowkes PhD); Federal University of Minas Gerais, Belo Horizonte, Brazil (Prof E B Franca PhD); James Cook University, Townsville, QLD, Australia (R C Franklin PhD); University of Basel, Basel, Switzerland (T Fürst PhD); Manhiça Health Research Center, Manhiça, Mozambique (A L Garcia-Basteiro MSc); Barcelona Institute for Global Health, Barcelona, Spain (A L Garcia-Basteiro MSc); The Task Force for Global Health, Decatur, GA, USA (T Gebre PhD); Ludwig Maximilians University, Munich, Germany (A T Gebremedhin MPH); Kilte Awlaelo Health and Demographic Surveillance System, Mekelle, Ethiopia (A A Gebru MPH, G B Hailu MSc); Agence de Medecine Preventive, Paris, France (B D Gessner MD); College of Medicine, Howard University, Washington, DC, USA (R F Gillum MD, A Mehari MD); College of Medicine, University of Hail, Hail, Saudi Arabia (I A Ginawi MD); University Hospital of Dijon, Dijon, France (Prof M Giroud MD); College of Health and Medical Sciences (H S Roba MPH), Haramaya University, Dire Dawa, Ethiopia (M D Gishu MS, A K Tura MPH); Kersa Health and Demographic Surveillance System, Harar, Ethiopia (M D Gishu MS); University of Massachusetts Boston, Boston, MA, USA (Prof P Gona PhD); Instituto de Investigaciones Cientifi cas y Servicios de Alta Tecnologia - INDICASAT-AIP, Ciudad del Saber, Panamá (A Goodridge PhD); Department of Health and Social Aff airs, Government of the Federated States of Micronesia, Palikir, Federated States of Micronesia (S V Gopalani MPH); Division of Epidemiology, Center for Public Health Sciences (A Goto PhD), National Cancer Center, Tokyo, Japan (M Inoue MD); Stattis LLC, Chisinau, Moldova (K F Greenwell PhD); West Virginia Bureau for Public Health, Charleston, WV, USA (R Gupta MD); Eternal Heart Care Centre and Research Institute, Jaipur,

india (R Gupta PhD); Department of Anthropology, University of Delhi, Delhi, India (V Gupta PhD); National Institute of Psychiatry Ramon de la Fuente, Mexico City, Mexico (R A Gutiérrez PhD); Aarhus University, Aarhus, Denmark (B Gyawali MPH, K M Iburg PhD); Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, Netherlands (J A Haagsma PhD); Brandeis University, Waltham, MA, USA (Y A Halasa MS, E A Undurraga PhD); Arabian Gulf University, Manama, Bahrain (Prof R R Hamadeh DPhil); Hamdan Bin Mohammed Smart University, Dubai, United Arab Emirates (S Hamidi PhD); Wayne County Department of Health and Human Services, Detroit, MI, USA (M Hammami MD); School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia (Prof G J Hankey MD); Harry Perkins Institute of Medical Research, Nedlands, WA, Australia (Prof G J Hankey MD); Western Australian Neuroscience Research Institute, Nedlands, WA, Australia (Prof G J Hankey MD); Parc Sanitari Sant Joan de Déu - CIBERSAM, Sant Boi de Llobregat (Barcelona), Spain (J M Haro MD); Universitat de Barcelona, Barcelona, Spain (J M Haro MD); Department of Psychiatry, University Medical Center Groningen (Prof H W Hoek MD), University of Groningen, Groningen, Netherlands (A K Tura MPH); Department of Epidemiology, Mailman School of Public Health (Prof H W Hoek MD), Columbia University, New York, NY, USA (Prof V Skirbekk PhD); Nevada Division of Public and Behavioral Health, Department of Health and Human Services, Carson City, NV, USA (M Horino MPH); Department of Pulmonology, Yokohama City University Graduate School of Medicine, Yokohama, Japan (N Horita MD); Albert Einstein College of Medicine, Bronx, NY, USA (Prof H D Hosgood PhD); Public Health Division, The Pacifi c Community, Noumea, New Caledonia (D G Hoy PhD); International Relations Division, Ministry of Health, Nay Pyi Taw, Myanmar (A S Htet MPhil); Department of Epidemiology and Health Statistics, School of Public Health, Central South University, Changsha, China (G Hu PhD); Cambridge Health Alliance, Cambridge, MA, USA (H Huang MD); Boston Medical Center (B T Idrisov MD), School of Medicine (G F Kwan MD), Boston University, Boston, MA, USA; Graduate School of Medicine (M Inoue MD), School of Public Health (Prof N Kawakami MD), University of Tokyo, Tokyo, Japan (K Shibuya MD); American Cancer Society, Atlanta, GA, USA (F Islami PhD); MCH Division, USAID - Global Health Bureau, HIDN, Washington, DC, USA (T A Jacobs MD); Department of Global and Community Health, George Mason University, Fairfax, VA, USA (K H Jacobsen PhD); Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia (Prof M B Jakovljevic PhD); UNFPA Asia and the Pacifi c Regional Offi ce, Bangkok, Thailand (H A F Jansen Drs); University of Aberdeen, Aberdeen, UK (M Javanbakht PhD); Postgraduate Institute of Medicine, Colombo, Sri Lanka (A U Jayatilleke PhD); Institute of Violence and Injury Prevention, Colombo, Sri Lanka (A U Jayatilleke PhD); Graduate School of Public Health (Prof S H Jee PhD), Yonsei University, Seoul, South Korea; Centre for Chronic Disease Control, New Delhi, India (P Jeemon PhD); George Institute for Global Health India, New Delhi, India (Prof V Jha DM); Department of Health Development, Institute of Industrial Ecological Sciences, University of Occupational and Environmental Health, Kitakyushu, Japan (Y Jiang PhD); School of Public Health (K Deribe MPH), College of Health Sciences, School of Public Health (W Tefera MPH), Addis Ababa University, Debre Zeit, Ethiopia (T Jibat MS,); Wageningen University, Wageningen, Netherlands (T Jibat MS); Department of Ophthalmology, Medical Faculty Mannheim, Ruprecht-Karls-University Heidelberg, Mannheim, Germany (Prof J B Jonas MD); University College Cork, Cork, Ireland (Z Kabir PhD); Society for Education, Action and Research in Community Health, Gadchiroli, India (Y Kalkonde MD); CSIR - Indian Institute of Toxicology Research, Lucknow, India (R Kamal MSc, C N Kesavachandran PhD); Department of Pulmonary Medicine, Zhongshan Hospital (J She MD), Fudan University, Shanghai, China (H Kan MD); University at Buff alo, Buff alo, NY, USA (A Kandel MBBS); Epidemiological and Statistical Methods Research Group, Helmholtz Centre for Infection Research, Braunschweig, Germany (A Karch MD); Hannover-Braunschweig Site, German Center for Infection Research, Braunschweig, Germany (A Karch MD); Quality and Equity Health Care, Kigali, Rwanda (C K Karema MSc); Case Western University Hospitals,

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Cleveland, OH, USA (C Karimkhani MD); Ministry of Health, Colombo, Sri Lanka (P Karunapema MD); Oklahoma State University, Tulsa, OK, USA (A Kaul MD); Institut de recherche de l’hôpital de Monttfort, Ottawa, ON, Canada (J F Kayibanda PhD); Institute of Tropical and Infectious Diseases, Nairobi, Kenya (P N Keiyoro PhD); School of Continuing and Distance Education, Nairobi, Kenya (P N Keiyoro PhD); Swansea University, Swansea, UK (Prof A H Kemp PhD); Burden of Disease Research Unit (R Matzopoulos PhD), Alcohol, Tobacco & Other Drug Research Unit (Prof C D Parry PhD), South African Medical Research Council, Cape Town, South Africa (A P Kengne PhD, Prof C S Wiysonge PhD); School of Public Health and Family Medicine (R Matzopoulos PhD), Department of Psychiatry (Prof D J Stein PhD), University of Cape Town, Cape Town, South Africa (A P Kengne PhD, Prof B M Mayosi DPhil, M Shey PhD, D A Watkins MD); Assuta Hospitals, Assuta Hashalom, Tel Aviv, Israel (Prof A Keren MD); Jordan University of Science and Technology, Irbid, Jordan (Prof Y S Khader ScD); Health Services Academy, Islamabad, Pakistan (E A Khan MPH); Department of Microbiology and Immunology, College of Medicine & Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates (G Khan PhD); College of Medicine (Prof Y H Khang MD), Graduate School of Public Health (Prof S Won PhD), Seoul National University, Seoul, South Korea; Executive Board of the Health Ministers’ Council for Cooperation Council States, Riyadh, Saudi Arabia (Prof T A M Khoja FRCP); Iranian Ministry of Health and Medical Education, Tehran, Iran (A Khosravi PhD); Ball State University, Muncie, IN, USA (J Khubchandani PhD); Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil (C Kieling MD); Korea Health Industry Development Institute, Cheongju-si, South Korea (C Kim PhD); Department of Health Sciences, Northeastern University, Boston, MA, USA (Prof D Kim DrPH); Soonchunhyang University, Seoul, South Korea (S Kim PhD); Southern University College, Skudai, Malaysia (Y J Kim PhD); Simmons College, Boston, MA, USA (R W Kimokoti MD); Department of Preventive Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan (Y Kokubo PhD); Division of Cardiology, Brown University, Providence, RI, USA (D Kolte MD); Center for Community Empowerment, Health Policy and Humanities, NIHRD, Jakarta, Indonesia (S Kosen MD); Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India (Prof P A Koul MD); Research and Development Unit, Parc Sanitari Sant Joan de Deu (CIBERSAM), Barcelona, Spain (A Koyanagi MD); Research Center of Neurology, Moscow, Russia (M Kravchenko PhD, Prof Y Y Varakin MD); Department of Demography and Public Health Research Institute (Prof B Kuate Defo PhD), Department of Social and Preventive Medicine, School of Public Health (Prof B Kuate Defo PhD), University of Montreal, Montreal, QC, Canada; Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil (Prof R S Kuchenbecker PhD); Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands (Prof E J Kuipers PhD); Arkansas State University, State University, AR, USA (V S Kulkarni PhD); National Centre for Epidemiology and Population Health, The Australian National University, Canberra, ACT, Australia (A Lal PhD, Prof R M Lucas PhD); Institute of Health Policy and Development Studies, National Institutes of Health, Manila, Philippines (Prof H Lam PhD); National Cancer Institute, Rockville, MD, USA (Q Lan PhD); Komfo Anokye Teaching Hospital, Kumasi, Ghana (D O Laryea MD); Department of Zoology, Lahore College for Women University, Lahore, Pakistan (A A Latif PhD); College of Optometry, Nova Southeastern University, Fort Lauderdale, FL, USA (J L Leasher OD); National Institute for Health Development, Tallinn, Estonia (M Leinsalu PhD); Stockholm Centre for Health and Social Change, Södertörn University, Stockholm, Sweden (M Leinsalu PhD); State University of New York, Albany, Rensselaer, NY, USA (R Leung PhD); Tuscany Regional Centre for Occupational Injuries and Diseases, Florence, Italy (M Levi PhD); San Francisco VA Medical Center, San Francisco, CA, USA (Y Li PhD); University of Haifa, Haifa, Israel (Prof S Linn MD); School of Medicine, Wayne State University, Detroit, MI, USA (Prof S E Lipshultz MD, Prof J D Wilkinson MD); Children’s Hospital of Michigan, Detroit, MI, USA (Prof S E Lipshultz MD); Rollins School of Public Health (E P Simard PhD), Emory University, Atlanta, GA, USA (Prof Y Liu PhD, Prof M R Phillips MD); Eastern Health Clinical School (B K Lloyd PhD), Monash University, Fitzroy, VIC, Australia; Turning Point, Eastern

Health, Melbourne, VIC, Australia (B K Lloyd PhD); UnionHealth Associates, LLC, St Louis, MO, USA (L Lo MD); Alton Mental Health Center, Alton, IL, USA (L Lo MD); University of Bari, Bari, Italy (Prof G Logroscino PhD); Aintree University Hospital National Health Service Foundation Trust, Liverpool, UK (Prof R Lunevicius PhD); School of Medicine, University of Liverpool, Liverpool, UK (Prof R Lunevicius PhD); Aswan University Hospital, Aswan Faculty of Medicine, Aswan, Egypt (M Magdy Abd El Razek MBBCh); National Center for the Prevention and Control of HIV/AIDS, Secretariat of Health, Mexico City, Mexico (C Magis-Rodriguez PhD); Social Security Organization Research Institute, Tehran, Iran (M Mahdavi PhD); Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, Netherlands (M Mahdavi PhD); Universidade Federal de Minas Gerais, Belo Horizonte, Brazil (Prof D C Malta PhD); Perelman School of Medicine (P A Meaney MD), University of Pennsylvania, Philadelphia, PA, USA (D J Margolis PhD); University Hospital Doctor Peset, University of Valencia, Valencia, Spain (J Martinez-Raga PhD); CEU Cardenal Herrera University, Moncada (Valencia), Spain (J Martinez-Raga PhD); Department of Health Sciences, University of York, York, UK (A J Mason-Jones PhD); Hospital Pedro Hispano/ULS Matosinhos, Matosinhos, Portugal (J Massano MD); Children’s Hospital of Philadelphia, Philadelphia, PA, USA (P A Meaney MD); University of Gondar, Gondar, Ethiopia (A B Mekonnen MS, B A Tedla BS); University of West Florida, Pensacola, FL, USA (P Memiah PhD); Saudi Ministry of Health, Riyadh, Saudi Arabia (Prof Z A Memish MD); College of Medicine, Alfaisal University, Riyadh, Saudi Arabia (Prof Z A Memish MD); United Nations Population Fund, Lima, Peru (W Mendoza MD); Robert Koch Institute, Berlin, Germany (G B M Mensink PhD); Department of Neurology, Helsinki University Hospital, Helsinki, Finland (A Meretoja PhD); Helsinki University Hospital, Comprehensive Cancer Center, Breast Surgery Unit, Helsinki, Finland (T J Meretoja PhD); University of Helsinki, Helsinki, Finland (T J Meretoja PhD); Ifakara Health Institute, Bagamoyo, Tanzania (F A Mhimbira MS); Pacifi c Institute for Research & Evaluation, Calverton, MD, USA (T R Miller PhD); Centre for Population Health, Curtin University, Perth, WA, Australia (T R Miller PhD); University of Ottawa, Ottawa, ON, Canada (E J Mills PhD); Neuroscience Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran (A Mohammadi PhD); Health Systems and Policy Research Unit, Ahmadu Bello University, Zaria, Nigeria (S Mohammed PhD); Institute for Maternal and Child Health, IRCCS “Burlo Garofolo”, Trieste, Italy (L Monasta DSc, M Montico MSc, L Ronfani PhD); Bureau of International Health Cooperation, Manila City, Philippines (J D Monis MSc); Department of Community Medicine, Gastrointestinal and Liver Disease Research Center, Preventive Medicine and Public Health Research Center, Iran University of Medical Sciences, Tehran, Iran (M Moradi-Lakeh MD); International Laboratory for Air Quality and Health (L Morawska PhD), School of Public Health and Social Work (J Sun PhD), Queensland University of Technology, Brisbane, QLD, Australia; National Center for Child Health and Development, Setagaya, Japan (R Mori PhD); Competence Center Mortality-Follow-Up of the German National Cohort (A Werdecker PhD), Federal Institute for Population Research, Wiesbaden, Germany (Prof U O Mueller PhD, R Westerman PhD); West Herts Hospitals NHS Trust, Watford, UK (M E Murdoch FRCP); AIDS & TB Unit, Ministry of Health and Child Care, Bindura, Zimbabwe (B Murimira MS); Zimbabwe National Family Planning Council, Harare, Zimbabwe (B Murimira MS); Federal University of Pelotas, Pelotas, Brazil (Prof J Murray PhD); School of Medical Sciences, University of Science Malaysia, Kubang Kerian, Malaysia (K I Musa MD); Graduate School of Public Health (Prof J B Nachega PhD), Public Health Dynamics Laboratory (A J Paternina Caicedo MD), University of Pittsburgh, Pittsburgh, PA, USA; Department of Psychiatry (Prof C D Parry PhD), Stellenbosch University, Cape Town, South Africa (Prof J B Nachega PhD, Prof S Seedat PhD, Prof C S Wiysonge PhD); Bloomberg School of Public Health (Prof J B Nachega PhD), Johns Hopkins University, Baltimore, MD, USA (B X Tran PhD); Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany (Prof G Nagel PhD, Prof D Rothenbacher MD); University of KwaZulu-Natal, Durban, South Africa (Prof K S Naidoo PhD, O Oladimeji MD, Prof B Sartorius PhD, E A Zegeye MS); Azienda

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Ospedaliera Papa Giovanni XXIII, Bergamo, Italy (Prof L Naldi MD, Prof G Remuzzi MD); Suraj Eye Institute, Nagpur, India (V Nangia MD); The George Institute for Global Health, Sydney, NSW, Australia (Prof B Neal PhD); Royal Prince Alfred Hospital, Sydney, NSW, Australia (Prof B Neal PhD); Faculty of Medicine, Fez, Morocco (Prof C Nejjari PhD); KEMRI Wellcome Trust, Kilifi , Kenya (Prof C R Newton MD); Ministry of Health and Social Welfare, Dar es Salaam, Tanzania (F N Ngalesoni MSc); KEMRI - Wellcome Trust Research Program, Nairobi, Kenya (P Nguhiu BPharm); Institute for Global Health Innovations, Duy Tan University, Da Nang, Vietnam (Q L Nguyen MD); Institute For Research, Socio-Economic Development and Communication, Yaoundé, Cameroon (P M Nkamedjie Pete MS); Department of Psychosomatic Medicine, Center for Internal Medicine and Dermatology, Charité Universitätsmedizin, Berlin, Germany (S Nolte PhD); Population Health Strategic Research Centre, School of Health and Social Development (S Nolte PhD), Deakin University, Geelong, VIC, Australia (Prof R H Osborne PhD); National Institute of Public Health, Saitama, Japan (M Nomura PhD); Department of Global Public Health and Primary Care (Prof S E Vollset DrPH), University of Bergen, Bergen, Norway (Prof O F Norheim PhD); Center for Research on Population and Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon (Prof C M Obermeyer DSc); Centre for Health Research, Western Sydney University, Sydney, NSW, Australia (F A Ogbo MPH); Department of Preventive Medicine, School of Medicine, Kyung Hee University, Seoul, South Korea (Prof I Oh PhD); Human Sciences Research Council, Durban, South Africa (O Oladimeji MD); Universidad Autonoma de Chile, Talca, Chile (Prof P R Olivares PhD); Center for Healthy Start Initiative, Lagos, Nigeria (B O Olusanya PhD, J O Olusanya MBA); Lira District Local Government, Lira Municipal Council, Uganda (J N Opio MPH); University of Arizona, Tucson, AZ, USA (Prof E Oren PhD); IIS-Fundacion Jimenez Diaz-UAM, Madrid, Spain (Prof A Ortiz PhD); St Luke’s International University, Tokyo, Japan (E Ota PhD); JSS Medical College, JSS University, Mysore, India (Prof Mahesh PA DNB); Department of Medical Humanities and Social Medicine, College of Medicine, Kosin University, Busan, South Korea (E Park PhD); California Air Resources Board, Sacramento, CA, USA (H Park PhD); Mount Sinai Health System, New York, NY, USA (T Patel MD); Sangath, Goa, India (Prof V Patel PhD); Krishan Institute of Medical Sciences, Deemed University, School of Dental Sciences, Karad, India (S T Patil MDS); Department of Community Health Sciences (Prof S B Patten PhD), University of Calgary, Calgary, AB, Canada (Prof M Tonelli MD); UK Department for International Development, Lalitpur, Nepal (D Paudel PhD); Health Research Centre of Angola, Caxito, Angola (J M Pedro MS); REQUIMTE/LAQV, Laboratório de Farmacognosia, Departamento de Química, Faculdade de Farmácia, Universidade do Porto, Porto, Portugal (Prof D M Pereira PhD); IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Bergamo, Italy (N Perico MD, Prof G Remuzzi MD); Flinders University, Adelaide, SA, Australia (Prof K Pesudovs PhD); Health Metrics Unit, University of Gothenburg, Gothenburg, Sweden (Prof M Petzold PhD); University of the Witwatersrand, Johannesburg, South Africa (Prof M Petzold PhD); Shanghai Jiao Tong University School of Medicine, Shanghai, China (Prof M R Phillips MD); Durban University of Technology, Durban, South Africa (J D Pillay PhD); Department of Public Health, Erasmus University Medical Center, Rotterdam, Netherlands (S Polinder PhD); Department of Community Medicine, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran (M Qorbani PhD); A T Still University, Kirksville, MO, USA (A Radfar MD); Research and Evaluation Division, BRAC, Dhaka, Bangladesh (M Rahman PhD); Hamad Medical Corporation, Doha, Qatar (S U Rahman FCPS); Society for Health and Demographic Surveillance, Suri, India (R K Rai MPH); ERAWEB Program, University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria (S Rajsic MD); University of Missouri, Columbia, MO, USA (M Raju PhD); Contech School of Public Health, Lahore, Pakistan (Prof S M Rana PhD); Contech International Health Consultants, Lahore, Pakistan (Prof S M Rana PhD); Department of Preventive Medicine, Wonju College of Medicine (C L Ranabhat PhD), Yonsei University, Wonju, South Korea; University of Michigan Health Systems, Ann Arbor, MI, USA (K Ranganathan MD); Walden University, Minneapolis, MN, USA (Prof A H Refaat PhD); Suez Canal University,

Ismailia, Egypt (Prof A H Refaat PhD); Department of Biomedical and Clinical Sciences L Sacco, University of Milan, Milan, Italy (Prof G Remuzzi MD); Hospital das Clinicas da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil (Prof A L Ribeiro MD); School of Psychology, University of Lincoln, Lincoln, UK (Prof A Rodriguez PhD); (ISGlobal) Instituto de Salud Global de Barcelona, Barcelona, Spain (D Rojas-Rueda PhD); Golestan Research Center of Gastroenterology and Hepatology, Golestan University of Medical Sciences, Gorgan, Iran (G Roshandel PhD); All India Institute of Medical Sciences, New Delhi, India (A Roy DM, R Sagar MD, M Satpathy PhD); BARC Hospital, HBNI University, Mumbai, India (N Roy MD); World Health Organization, Accra, Ghana (B B Sackey MS); All India Institute of Medical Sciences, New Delhi, India (R Sagar MD, M Satpathy PhD); Development Research and Projects Center, Abuja, Nigeria (M M Saleh MPH); Marshall University J Edwards School of Medicine, Huntington, WV, USA (J R Sanabria MD); Case Western Reserve University, Cleveland, OH, USA (J R Sanabria MD); Universidad Ciencias Aplicadas y Ambientales, Bogotá, Colombia (R Sarmiento-Suarez MPH); Centre for Disease Burden (Prof S E Vollset DrPH), Norwegian Institute of Public Health, Oslo, Norway (M Savic PhD, Prof V Skirbekk PhD); Marshall University, Huntington, WV, USA (M Sawhney PhD); Global Perspective Studies Unit, Food and Agriculture Organization, Rome, Italy (J Schmidhuber PhD); Federal University of Santa Catarina, Florianópolis, Brazil (I J C Schneider PhD, D A S Silva PhD); Hypertension in Africa Research Team (HART), North-West University, Potchefstroom, South Africa (Prof A E Schutte PhD); Burden of Disease Research Unit (R Matzopoulos PhD), Alcohol, Tobacco & Other Drug Research Unit (Prof C D Parry PhD), South African Medical Research Council, Potchefstroom, South Africa (Prof A E Schutte PhD); Department of Public Health, An-Najah University, Nablus, Palestine (A Shaheen PhD); Independent Consultant, Karachi, Pakistan (M A Shaikh MD); Indian Institute of Technology Ropar, Rupnagar, India (R Sharma MA); Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA (J Shen PhD); National Institute of Infectious Diseases, Tokyo, Japan (M Shigematsu PhD); Sandia National Laboratories, Albuquerque, NM, USA (M Shigematsu PhD); Department of Public Health Science, Graduate School (Prof M Shin PhD), Department of Preventive Medicine, College of Medicine (S Yoon PhD), Korea University, Seoul, South Korea; Work Organizations, Work Disability Prevention, The Finnish Institute of Occupational Health, Helsinki, Finland (R Shiri PhD); Washington State University, Spokane, WA, USA (K Shishani PhD); Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK (I Shiue PhD); Reykjavik University, Reykjavik, Iceland (I D Sigfusdottir PhD); Feinberg School of Medicine (J I Silverberg MD), Department of Preventive Medicine (Y Yano MD), Northwestern University, Chicago, IL, USA; Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India (O P Singh PhD); Institute for Human Development, New Delhi, India (P K Singh PhD); Stavanger University Hospital, Stavanger, Norway (K Søreide PhD); Instituto de Investigación Hospital Universitario de la Princesa, Universidad Autónoma de Madrid, Madrid, Spain (Prof J B Soriano PhD); Department of Clinical Neurological Sciences, Western University, London, ON, Canada (L A Sposato MD); Department of Community Medicine, International Medical University, Kuala Lumpur, Malaysia (C T Sreeramareddy MD); Institute of Public Health, University Hospital Heidelberg, Heidelberg, Germany (H Stahl PhD); University Medical Centre Freiburg, Freiburg, Germany (H Stahl PhD); Attikon University Hospital, Athens, Greece (V Stathopoulou PhD); Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, University Hospital Munich, Munich, Germany (N Steckling MSc); University of East Anglia, Norwich, UK (Prof N Steel PhD); South African Medical Research Council Unit on Anxiety & Stress Disorders, Cape Town, South Africa (Prof D J Stein PhD); Luxembourg Institute of Health, Strassen, Luxembourg (S Stranges PhD); School of Health and Related Research, University of Sheffi eld, Sheffi eld, UK (M Strong PhD); Institute for Resilient Regions, University of Southern Queensland, Springfi eld, QLD, Australia (J Sun PhD); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (B F Sunguya PhD); Indian Council of Medical Research, New Delhi, India (S Swaminathan MD);

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Departments of Criminology, Law & Society, Sociology, and Public Health, University of California, Irvine, Irvine, CA, USA (Prof B L Sykes PhD); Department of Medicine, University of Valencia, INCLIVA Health Research Institute and CIBERSAM, Valencia, Spain (Prof R Tabarés-Seisdedos PhD); School of Social Work, University of Illinois at Urbana-Champaign, Champaign, IL, USA (K M Tabb PhD); Ministry of Health, MINSANTE, Yaoundé, Cameroon (R T Talongwa MD); Ministry of Health, Amman, Jordan (M R Tarawneh MPH); New York Medical College, Valhalla, NY, USA (M Tavakkoli MD); Department of Biology, Colgate University, Hamilton, NY, USA (B Taye PhD); James Cook University, Cairns, QLD, Australia (B A Tedla BS); Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA (A S Terkawi MD); Outcomes Research Consortium (A S Terkawi MD), Cleveland Clinic, Cleveland, OH, USA (Prof E M Tuzcu MD); University Of Gondar, Gondar, Ethiopia (G A Tessema MPH); School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India (Prof J Thakur MD); Adaptive Knowledge Management, Victoria, BC, Canada (A J Thomson PhD); WorldFish, Penang, Malaysia (A L Thorne-Lyman ScD); Nelson Institute of Environmental Medicine, School of Medicine, New York University, Tuxedo, NY, USA (Prof G D Thurston ScD); National Center for Child Health and Development, Tokyo, Japan (R Tobe-Gai PhD); Institute of Public Health, Faculty of Health Sciences, Jagiellonian University Medical College, Kraków, Poland (R Topor-Madry PhD); Faculty of Health Sciences, Wroclaw Medical University, Wroclaw, Poland (R Topor-Madry PhD); Aristotle University of Thessaloniki, Thessaloniki, Greece (Prof F Topouzis PhD); Hanoi Medical University, Hanoi, Vietnam (B X Tran PhD); Department of Population Sciences and Development, Faculty of Economics and Management, University of Kinshasa, Kinshasa, Democratic Republic of the Congo (Z Tsala Dimbuene PhD); African Population and Health Research Center, Nairobi, Kenya (Z Tsala Dimbuene PhD); Parc Sanitari Sant Joan de Déu, Fundació Sant Joan de Déu, Universitat de Barcelona, CIBERSAM, Barcelona, Spain (S Tyrovolas PhD); Department of Internal Medicine, Federal Teaching Hospital, Abakaliki, Nigeria (K N Ukwaja MD); Ebonyi State University, Abakaliki, Nigeria (C J Uneke PhD); Warwick Medical School, University of Warwick, Coventry, UK (O A Uthman PhD); UKK Institute for Health Promotion Research, Tampere, Finland (Prof T Vasankari PhD); University of Brasilia, Brasília, Brazil (Prof A M N Vasconcelos PhD); Raffl es Neuroscience Centre, Raffl es Hospital, Singapore, Singapore (N Venketasubramanian FRCP); University of Bologna, Bologna, Italy (Prof F S Violante MD); National Research University Higher School of Economics, Moscow, Russia (Prof V V Vlassov MD); National Cancer Institute, Mexico City, Mexico (P Volkow MD); National Autonomous University of Mexico, Mexico City, Mexico (P Volkow MD); National Institute for Occupational Safety and Health, Washington, DC, USA (G R Wagner MD); VA Medical Center, Washington, DC, USA (M T Wallin MD); Neurology Department, Georgetown University, Washington, DC, USA (M T Wallin MD); McGill University, Montreal, QC, Canada (S Weichenthal PhD); Department of Research, Cancer Registry of Norway, Institute of Population-Based Cancer Research, Oslo, Norway (E Weiderpass PhD); Department of Community Medicine, Faculty of Health Sciences, University of Tromsø, The Arctic University of Norway, Tromsø, Norway (E Weiderpass PhD); Genetic Epidemiology Group, Folkhälsan Research Center, Helsinki, Finland (E Weiderpass PhD); Royal Children’s Hospital, Melbourne, VIC, Australia (R G Weintraub MBBS); German National Cohort Consortium, Heidelberg, Germany (R Westerman PhD); Children’s Hospital of Michigan, Detroit, MI, USA (Prof J D Wilkinson MD); National Institute for Health Research Comprehensive Biomedical Research Centre, Guy’s & St Thomas’ NHS Foundation Trust and King’s College London, London, UK (Prof C D Wolfe MD); Evelina London Children’s Healthcare, St Thomas’ Hospital, London, UK (I Wolfe PhD); Royal Cornwall Hospital, Truro, UK (Prof A D Woolf FRCP); St Paul’s Hospital, Millennium Medical College, Addis Ababa, Ethiopia (M Wubshet PhD); Department of Neurology, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China (Prof G Xu PhD); Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu Natal, Durban, South Africa (B Yakob PhD); Global Health Research Center, Duke Kunshan

University, Kunshan, China (Prof L L Yan PhD); Social Work and Social Administration Department and The Hong Kong Jockey Club Centre for Suicide Research and Prevention, University of Hong Kong, Hong Kong, China (Prof P Yip PhD); Department of Biostatistics, School of Public Health, Kyoto University, Kyoto, Japan (N Yonemoto MPH); Jackson State University, Jackson, MS, USA (Prof M Z Younis DrPH); Department of Epidemiology and Biostatistics, School of Public Health (Prof C Yu PhD), Global Health Institute (Prof C Yu PhD), Wuhan University, Wuhan, China; University Hospital, Setif, Algeria (Prof Z Zaidi PhD); Faculty of Medicine, Mansoura University, Mansoura, Egypt (Prof M E Zaki PhD); EcoHealth Alliance, New York, NY, USA (C Zambrana-Torrelio MS); Instituto de Ecologia-Bolivia, La Paz, Bolivia (C Zambrana-Torrelio MS); World Health Organization, Windhoek, Namibia (T Zapata MD); Ethiopian Public Health Institute, Addis Ababa, Ethiopia (E A Zegeye MS); Oregon Health and Science University, Portland, OR, USA (D Zonies MD)

ContributorsStephen S Lim, Nancy Fullman, and Christopher J L Murray prepared the fi rst draft. Michael J Kutz, Ellen M Goldberg, and David M Pigott constructed the indices. Claire R McNellan, Nancy Fullman, and Kate Allen constructed the UHC tracer intervention indicator. Stephen S Lim and Christopher J L Murray provided overall guidance. Meghan D Mooney managed the project. Stephen S Lim, Nancy Fullman, Christopher J L Murray, and Meghan D Mooney fi nalised the manuscript based on comments from other authors and reviewer feedback. Helen E Olsen managed the appendices. All other authors provided data or developed models for SDG indicators, reviewed results, initiated modelling infrastructure, or reviewed and contributed to the report.

Declaration of interestsBruce Bartholow Duncan and Maria Inês Schmidt have received additional funding from the Brazilian Ministry of Health (Process number 25000192049/2014-14). Itamar S Santos reports grants from FAPESP (Brazilian public agency) outside the submitted work. Rafael Tabarés-Seisdedos was supported in part by grant PROMETEOII/2015/021 from Generalitat Valenciana and the national grand PI14/00894 from ISCIII-FEDER. Ai Koyanagi’s work is supported by the Miguel Servet contract fi nanced by the CP13/00150 and PI15/00862 projects, integrated into the National R + D + I and funded by the ISCIII—General Branch Evaluation and Promotion of Health Research—and the European Regional Development Fund (ERDF-FEDER). Benjamin C Cowie acknowledges funding support from the Australian Government Department of Health and the Royal Melbourne Hospital Research Funding Program. Elisabeth Barboza Franca acknowledges funding from the Brazilian Ministry of Health (Project number 25000192049/2014-14). Aletta E Schutte is funded by the Medical Research Council of South Africa, and the South African Research Chair Initiative by the National Research Foundation. Amador Goodridge acknowledges funding from Sistema Nacional de Investigadores de Panamá-SNI. José das Neves was supported in his contribution to this work by a Fellowship from Fundação para a Ciência e a Tecnologia, Portugal (SFRH/BPD/92934/2013). Thomas Fürst has received fi nancial support from the Swiss National Science Foundation (SNSF; project number P300P3-154634). Jost B Jonas reports personal fees from being a consultant for Mundipharma and a patent holder with Biocompatibles UK (title: Treatment of eye diseases using encapsulated cells encoding and secreting neuroprotective factor and/or anti-angiogenic factor; patent number: 20120263794), and has applied for patent with University of Heidelberg (title: Agents for use in the therapeutic or prophylactic treatment of myopia or hyperopia; Europäische Patentanmeldung 15 000 771.4) outside the submitted work. Stefanos Tyrovolas’s work is supported by the Foundation for Education and European Culture (IPEP), the Sara Borrell postdoctoral programme (reference number CD15/00019) from the Instituto de Salud Carlos III (ISCIII), Spain, and the Fondos Europeo de Desarrollo Regional (FEDER). Beatriz Paulina Ayala Quintanilla acknowledges the institutional support of PRONABEC (National Program of Scholarship and Educational Loan), provided by the Peruvian Government, while studying for her doctoral course at the

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36 www.thelancet.com Published online September 21, 2016 http://dx.doi.org/10.1016/S0140-6736(16)31467-2

Judith Lumley Centre of La Trobe University funded by PRONABEC. Manami Inoue is the benefi ciary of a fi nancial contribution from the AXA Research fund as chair holder of the AXA Department of Health and Human Security, Graduate School of Medicine, The University of Tokyo from Nov 1, 2012; the AXA Research Fund has no role in this work. Olanrewaju Oladimeji is an African Research Fellow at Human Sciences Research Council (HSRC) and a Doctoral Candidate at the University of KwaZulu-Natal (UKZN), South Africa, and acknowledges the institutional support by leveraging on the existing organisational research infrastructure at HSRC and UKZN. Sun Ha Jee has been funded by a grant of the Korean Health Technology R&D project (HI14C2686), South Korea. Dan J Stein reports personal fees from Lundbeck, Novartis, AMBRF, Biocodex, Sevier, SUN, and CIPLA; and grants from NRGF and MRC outside the submitted work. Mayowa O Owolabi’s work is supported by U54 HG007479 from the US National Institutes of Health. All other authors declare no competing interests.

AcknowledgmentsWe thank the countless individuals who have contributed to the Global Burden of Disease Study 2015 in various capacities. The data used in this paper came from the 2009–10 Ghana Socioeconomic Panel Study Survey, which is a nationally representative survey of more than 5000 households in Ghana. The survey is a joint eff ort undertaken by the Institute of Statistical, Social and Economic Research (ISSER) at the University of Ghana, and the Economic Growth Centre (EGC) at Yale University. It was funded by the Economic Growth Center. At the same time, ISSER and the EGC are not responsible for the estimations reported by the analyst(s). HBSC is an international study carried out in collaboration with WHO/EURO. A list of principal investigators in each country can be found online. The Panel Study of Income Dynamics is primarily sponsored by the National Science Foundation, the National Institute on Aging, and the National Institute of Child Health and Human Development and is conducted by the University of Michigan. This analysis uses data or information from the LASI Pilot micro data and documentation. The development and release of the LASI Pilot Study was funded by the National Institute on Ageing/National Institute of Health (R21AG032572, R03AG043052, and R01 AG030153). Collection of these data was made possible by the US Agency for International Development (USAID) under the terms of cooperative agreement GPO-A-00-08-000_D3-00. The opinions expressed are those of the authors and do not necessarily refl ect the views of USAID or the US Government. Data for this research were provided by MEASURE Evaluation, funded by the USAID. Views expressed do not necessarily refl ect those of USAID, the US Government, or MEASURE Evaluation. The Palestinian Central Bureau of Statistics granted the researchers access to relevant data in accordance with licence number SLN2014-3-170, after subjecting data to processing aiming to preserve the confi dentiality of individual data in accordance with the General Statistics Law—2000. The researchers are solely responsible for the conclusions and inferences drawn upon available data. We thank the Russia Longitudinal Monitoring Survey, RLMS-HSE, conducted by the National Research University Higher School of Economics and ZAO “Demoscope” together with Carolina Population Center, University of North Carolina at Chapel Hill and the Institute of Sociology RAS for making these data available. This research used data from the National Health Survey 2009–10, and we gratefully acknowledge the Ministry of Health, Survey copyright owner, for use of the database. All results of the study are those of the authors and in no way committed to the ministry. The following individuals acknowledge various forms of institutional support: Amanda G Thrift is supported by a fellowship from the Australian National Health and Medical Research Council (GNT1042600). Panniyammakal Jeemon is supported by the Wellcome Trust–DBT India Alliance, Clinical and Public Health, Intermediate Fellowship (2015–20). Boris Bikbov, Giuseppe Remuzzi, and Norberto Perico acknowledge that their contribution to this paper has been on behalf of the International Society of Nephrology (ISN) as a follow-up of the activities of the GBD 2010 Genitourinary Diseases Expert Group. Tonatiuh Barrientos-Gutierrez and E Filipa de Castro acknowledge that the data shared on Water and Sanitation for Mexico, was derived from the “Encuesta Nacional de Niños, Niñas y Mujeres en México 2015”, which is the implementation in Mexico of the Multiple Indicators Cluster Survey (MICS) carried out with the fi nancial support of UNICEF. Miriam Levi would like to acknowledge the

institutional support received from CeRIMP, Regional Centre for Occupational Diseases and Injuries, Tuscany Region, Florence, Italy. Charles Wolfe’s research was funded/supported by the National Institute for Health Research (NIHR) Biomedical Research Centre based at Guy’s and St Thomas’ NHS Foundation Trust and King’s College London. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. No individuals acknowledged receiving additional compensation for their eff orts.

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