to frame policies around UHC:
•Who in the population is covered?
•What services are they covered by?
•What level of financial protection do they have when accessing services?
First, these three questions are critical to ask while planning for UHC and require an evidence-based analysis of the current situation. This in turn requires that a vision document or a blueprint of intent is drawn up within countries that visualize the various steps that are required to move towards UHC. Whether and to what extent the steps are adhered to subsequently is important, but the intent document is a key indicator of the government’s prioritization and sincerity in implementing UHC.
Second, it is now well-established that UHC works well with predominantly compulsory financing mechanisms like taxes or social health insurance contributions (Kutzin, 2016). This makes public finance critical, and evidence exists to show that OOPS is inversely related to government spending (Kutzin, 2016). Therefore, public finances on health are important indicators of a government’s prioritization of the health sector.
Yet a third criterion to understand progress towards UHC is to what extent countries have been able to consolidate and merge fragmented pools. It has been argued that fragmented coverage tends to be ineffective, inefficient, and inequitable, and countries should aim for full population coverage from the very beginning (Nicholson et al., 2015). For example, basing priority-setting on socio-demographic characteristics like gender, ethnicity, religion, etc. may not be the most efficient way of progressing towards UHC (Norheim , 2016).
The WHO proposes three criteria that countries can consider in evaluating which services to cover: cost-effectiveness, priority to the worse off, and financial risk protection.3 By these criteria, primary health care services are at the top of the list, since these reach the widest of populations and are the first contact point between the patient and the health system. Access to medicines also seems to be high on the list of services that people care about (Wirtz et al., 2016). Thus, countries that have been able to make primary health services accessible and available for their populations can be said to have taken a significant step towards a UHC: a more comprehensive approach can only be built on a functional primary health care system.
There is some debate and differences among experts on whether or not cost-effectiveness should be given an equal weightage as a criterion for giving priority to the worse off (Norheim et al., 2014). There may be services that are not high up on the cost-effectiveness chart but are mostly targeted at the worse off, and therefore improve utility significantly. In fact, priority to the worse off and financial risk protection may relatively be more important, and within these interventions one can choose the most cost-effective one. Thus, this criterion is not separately evaluated in the country context. Instead, we use the more standard way of looking at financial protection by analyzing trends in OOPS and impoverishment, both of which would give a clear indicator of the extent of protection offered to population in general and to the poor in particular.
There are two other parameters that are important in the context of UHC: the first one is to study the reform process that precedes and accompanies the rolling out of the UHC. While many of the indicators mentioned above are relevant to analyze reforms, we study here the presence or absence of continuous and incremental reforms in these countries, to understand the intent to stay on course for reaching the objectives laid out in the vision document. Whether the reforms were reforms in the true sense and were successful are not the main questions: it is whether the countries could monitor and evaluate their policies around UHC and attempt course-correction if required.
The second parameter has to do with governance; do countries with better governance perform better to improve access to health services? In fact, governance could also influence the body of reforms and their implementation. While governance is a difficult and different area of enquiry, some summary measures might be helpful to understand where the BRICS countries stand and to understand their performance in the context of UHC.
Finally, an important objective is to see how India has fared in improving access to health services for its population and whether there are lessons that it can learn from the experiences of the other countries within the BRICS. The study necessarily draws heavily from existing literature on individual country analyses. Comparable data is sparse, but wherever possible, we have used existing data to make our points and arrive at conclusions.
Health Status and Disease Burden in BRICS
Do the countries have a similar disease burden? Table 1 gives the top 10 causes of deaths across the BRICS countries and changes between 2005 and 2015 from the 2015 Global Burden of Diseases.
On the whole, non-communicable diseases (NCDs) dominate the top 10 causes of mortality in these countries. Ischemic heart disease, cerebrovascular diseases, and COPD are the three common causes within the top 10 causes of mortality in BRICS nations. Some other relatively common causes of mortality in the top 10 are road injuries, diabetes, and Alzheimer’s disease. Among communicable diseases, lower respiratory infections are common across countries as a major cause of deaths. South Africa is the only country to have as many as four communicable (and preventable) diseases among the top 10 causes of mortality, viz., HIV/AIDS, lower respiratory infections, tuberculosis, and diarrheal diseases. India follows closely with three (barring HIV/AIDS) of these diseases being the main causes of mortality. The decadal change in the share of each disease in total mortality shows a mixed picture, except for communicable diseases, which show a decline for all countries barring lower respiratory infections in Brazil. The top 10 causes of mortality that register the highest decadal growth are road injuries (Brazil), Alzheimer disease (Russia and China), chronic kidney disease (India), and diabetes (South Africa). On the other hand, top mortality causers with lowest decadal growth are interpersonal violence (Brazil), self-harm (Russia), neonatal pre-term birth (India), COPD (China), and HIV/AIDS (South Africa). The increasing burden of NCDs in BRICS countries is a very important challenge with implications about out-of-pocket spending (OOPS) on the one hand and response of the health system — including UHC — on the other (Jakovljevic and Olivera, 2015). In fact, countries with significant dual burden of diseases face more challenges of investing limited funds across competing uses.
Table 1:Burden of disease in BRICS.
Source: Global Burden of Disease 2015, Institute of Health Metrics and Evaluation.
A set of four basic health indicators have been presented in Table 2 to show how the countries are faring in terms of specific health outcomes, and a summary outcome index has been constructed to make the comparisons easier.
Table 2:Health outcomes in BRICS.
Note: The index for a country is an average of its normalized score in each indicator. The process of normalization is (X−Xmin)/(Xmax−Xmin), where X is the indicator.
Source: World Development Indicators, World Bank and World Health Statistics, WHO.
The difference between the highest (China) and the lowest (South Africa) life expectancy at birth is as high as 19 years. The low LEB in South Africa is primarily on account of the HIV/AIDS epidemic because of which it declined from 62 years in 1992 to 52 in 2005. Russia currently is the best performer in basic outcome indicators of maternal and child health. India fares the worst with
