more than four times and maternal mortality rate close to seven times that of Russia. When compared with the other most populous country, China, India’s maternal and child health outcomes are alarming — a fact that underlines the importance of provision of and access to primary care.
Russia has made the highest improvement in life expectancy at birth over time (2000–2014), as exemplified by the trend growth rate, followed by India. However, for child health outcomes, India shows the least improvement in these 15 years while China shows the maximum improvement. Russia registers the largest decline in maternal mortality in this one and half decades, while South Africa actually shows an increase in maternal mortality. China achieves the top position in the overall index of health outcome, followed by Russia, Brazil, India, and South Africa. Needless to say, country-level aggregates conceal the disparities in health outcomes across gender and socio-economic groups, which is an important indicator of equitable health outcomes and access to services.
Progress Towards UHC: Selected Indicators
Access to Primary and Basic Care
While summary statistics are available that indicate what percentage of population is covered, these are slightly misleading as indicators of UHC coverage because these include different programs and schemes, many of which may not be what the country needs or aligned to the philosophy of UHC. Instead, we use access to quality services for primary health care needs of the population along with a set of recommended indicators for monitoring progress towards UHC, but mainly to understand access to primary care across countries. Health MDG-related UHC indicators or tracer indicators (Marten et al., 2014) include demand for family planning met by modern methods, antenatal care visits, skilled attendants at birth, immunization coverage, improved water and sanitation, access to antiretroviral (ARV) therapy, and TB treatment. Further, Sustainable Development Goal 3.8 specifically mentions the importance of access to “safe, effective, quality and affordable essential medicines and vaccines for all”, making access to medicines an important indicator as well (Wirtz et al., 2016).
However, in the absence of data on all the indicators, we select the ones with data for all the five countries and construct an index based on these indicators given in the last column (Table 3).
The country with the best access to basic services is Brazil, followed by China and Russia, respectively. South Africa and India trail behind, with India being at the bottom of the ranking for these indicators. The most alarming status is that of sanitation in India. Only 40% of Indians have access to improved sanitation. In fact, while India is certainly an outlier in this respect, other BRICS countries too are noticeably short of universal access to improved sanitation. This is applicable to tuberculosis case detection rate as well.
Table 3:Access to primary and preventive care in BRICS.
Notes: The family planning indicators are for the years 2006 (Brazil), 2001 (China), 2008 (India), 2011 (Russia), and 2004 (South Africa). The skilled birth attendance indicators is for the years 2013 (Brazil and India), 2014 (China), 2008 (Russia), and 2004 (South Africa). The source for both is World Health Statistics, WHO. 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.
Financial Protection
Next, we look at the second dimension of path to UHC — financial protection. The share of out-of-pocket expenditure in total health expenditure of a country is a commonly used indicator of the need for financial protection — especially of the poor — from the costs of health care.
Figure 1 presents a 15-year trend in this indicator for BRICS. India has the highest share of OOP in total health expenditure, while South Africa has the lowest. In fact, India is the only country in this group to have more than half of its health expenditure financed out-of-pocket. All the countries except Russia show a decline in the share of OOP over the years, although the rate of decline varies. The most significant decline has happened in the case of China where the share of OOP declined by 27 percentage points in 15 years, the same being only 6 percentage points for India. Russia presents a peculiar case where the share of OOP in total health expenditure has increased by 16 percentage points in the last 15 years.
Figure 1:Out-of-pocket expenditure (OOPS) as % of total health expenditure (THE).
Source: Global Health Expenditure Database, World Health Organization.
The immediate fallout of a high-OOP share in total health spending is the risk of catastrophic expenditures and impoverishment. The only indicator for which data was available to measure catastrophic expenditure was for surgical care (Figure 2). India is the most vulnerable by this measure of financial vulnerability from OOP health care expenses. Needless to state that data for the entire spectrum of health services (not only surgical and anesthetic) would have given a more nuanced picture, but would probably not have altered India’s ranking.
Figure 2:Risk of catastrophic expenditure for surgical care (% of people at risk), 2014.
Note: Catastrophic expenditure is defined as direct out-of-pocket payments for surgical and anesthesia care exceeding 10% of total income.
Source: World Development Indicators, World Bank.
Figure 3:Health expenditure per capita (current US dollar).
Source: World Development Indicators, World Bank.
Financing for UHC
How do the countries compare in terms of how much is spent on health? Figure 3 gives the total per capita expenditure, which includes both public and private finances.
Per capita health expenditure in 2014 was the highest ($947) in Brazil (see Figure 3), 13 times that of India at $75. However, the per capita GDP of Brazil was only five times that of India. Brazil has historically been the bigger and the most consistent health spender among BRICS. Between 1995 and 2005, the highest increase (20 times) in per capita health spending, however, happened in China followed very distantly by South Africa (eight times). Viewed in conjunction with Figure 1, it can be stated that except Russia, the share of private OOP expenditure had an increasingly marginal contribution to this increase in total expenditure over time. In other words, much of this increase in per capita total health expenditure in China has been on account of increased government spending on health.
While not measured as an indicator of UHC, government health finances remain a critical component of UHC, whether spent on expanding its own services to provide access or to expand a social health insurance program, primary care, or pre-payment systems. Higher GDP going into the health of a country has been seen as an important indicator of political commitment (Gottret and Schieber, 2006; Stuckler et al., 2010).
