In 1996, the Russian Constitution provided all citizens right to free healthcare under Mandatory Medical Insurance in 1996. The National Priority Project in Public Health came into being in early 2000s. With this came a series of reforms and changes in the health system — introduction of medical insurance, competitive contracting, co-payments, and privatization — that resulted in rapid and “massive destatization” (Judyth, 1998). The system did not perform as expected mainly because it was not preceded by administrative, regulatory, and legal reforms. OOPS increased and state finances declined sharply. Two channels of government financing were created, one based on wage taxes and the other on general tax revenues, the latter being the more unstable source (Danishevski et al., 2006). The underfunding of inputs, including that of personnel, created “shadow commercialization”, which essentially meant that government-appointed medical personnel used informal shadow payments for their services (Blam and Kovalev, 2005).
In 2010, the law on Federal Mandatory Insurance Fund (FOMS) was introduced in Russia, In 2012, a set of measures was announced designed to overhaul the health care system in Moscow, and some major proposals around personnel and equipment were made that caused a significant level of controversies and protests in the country. The Russian system of decentralization has raised many concerns; the three tiers of the system — federal, regional, and municipal — each have their revenue-collecting and service-providing functions, but the management and regulation of the entire system remains complex (Danishevski et al., 2006). The chronic deficit of FOMS, mismatch between fixed rates for medical services and actual costs, centralized administration of an attempted decentralized system, and chronic personnel shortage have led led to a situation which has often led to alarmist conclusions (Epple, 2015) and a cry for real reforms.6
With relatively high health spending, Russia is a case of substantial inefficiencies in spending which translates into suboptimal health outcomes, high OOPS, and significant inequalities in access and financing across regions and economic and social classes (Linda, 2015; Gordeev et al., 2011). Private health insurance has increased over the years in Russia (Popovich et al., 2011). While its health outcomes are close to that of China and Brazil, in comparison to OECD countries, Russia does not perform that well. However, there is evidence of sincerity in health sector reforms, and evidence does suggest that incremental changes have been taking place, though a much more evidence-based approach is required to yield superior results.
South Africa
The post-Apartheid period in South Africa saw a number of incremental reforms in the health sector to address the immense inequalities in access and outcome that was the norm during the apartheid regime. This included public health legislation and policies and a unified national health system, increasing infrastructure at the primary care level and removing user fees for maternal and child health services to name a few (Schaay et al., 2011). Despite this, the country saw unprecedented worsening of burden of disease, with HIV and TB wiping out much of the gains achieved through development.
To tackle the worsening health situation, in 2008, the government brought out the Health Sector Road report which resulted in the 10-Point Plan, which was intended ‘to guide government health policy and identify opportunities for coordinated public and private health sector efforts, in order to improve access to affordable, quality health care in South Africa’ (Schaay et al., 2011). A performance agreement between the President and the Minister of Health was signed in October 2010 for the implementation of the Negotiated Service Delivery Agreement (NSDA) for the Health Sector. The NSDA process requires that government departments harmonize the implementation of their respective service delivery agreements so as to facilitate delivery of the 12 key outcomes.
In 2011, the Green Paper on National Health Insurance was brought out which contained the principles for developing National Health Insurance (NHI). The objectives were to improve access to quality healthcare services and provide financial risk protection against health-related catastrophic expenditures. The proposal visualized the development of comprehensive healthcare to be provided through accredited and contracted public and private providers, with a strong focus on health promotion and prevention services at the community and household level. The proposal also contained a realistic target timeline, with the first 5 years to be used to strengthen the public sector in preparation for new NHI systems. The plan was to launch the new central NHI fund in 2014/2015 (National Health Insurance, 2013).
However, the NHI did not quite take off, and in 2015 the government released the White Paper on NHI. The paper proposed that NHI will be made compulsory and will be introduced in three phases over a 14-year period. In Phase I, focus will be on strengthening the public sector. In the second phase, population registration and creation of a transitional fund to purchase non-specialist primary care would be the focus. Finally, in Phase III, the aim will be to operationalize the NHI fund fully and make it a strategic purchaser and single payer of comprehensive health services, including specialist services (Gray and Vawda, 2016).
While it is early to comment on the progress and implementation of the NHI, there is some concern that the necessary homework to make NHI a reality remains to be done. For example, there have been delays in operationalizing the independent Office of Health Standards Compliance, necessary for ensuring compliance with standards laid down for treatment. Some of the changes envisaged in the White paper require far-reaching legislative changes as well, in for example, the National Health Act and the Medical Schemes Act, but details are not laid out in the White paper on how exactly such changes should be brought about (Gray and Vawda, 2016).
India
The constitution of India considers the ‘right to life’ to be fundamental and obliges the government to ensure the ‘right to health’ for all, without any discrimination. The Constitution indicates the government’s role in the health sector and lays down obligations on the Central Government, but makes health a State subject. To a significant extent, India’s health sector has been shaped by the federal structure of the country and center–state divisions of functions, responsibilities, and financing.
The total health expenditure in India for 2013–2014 was 4.02% of the country’s GDP, with government expenditure at 1.15% of GDP (National Health Accounts, 2013–2014), which is lower than the average for low-income countries (National Health Profile, 2016). Out of total health expenditure in India, household out-of-pocket expenditures are 69.1%. The high OOPS and low public investment have remained more or less the main features of the Indian health care system over many years.
There have been a few attempts at moving towards a wider health coverage system, notably the High-Level Expert Group set up by the Planning Commission, which brought out a blueprint of the possible ways India could move towards UHC. With a change in the government at the Center, a National Health Assurance Mission was set up as well, which submitted another blueprint of UHC to the government. The recommendations of these committees were not implemented. Apart from these, there have been two major programs which can be thought of as highlights of India’s health sector journey over the years. These are the National Rural Health Mission (NRHM) launched in 2005 and the Rashtriya Swasthya Bima Yojana (RSBY) launched in 2008.
The NRHM — now called the National Health Mission or NHM — can possibly be called a true health sector reform in that it changed in some fundamental ways the workings of the health systems in the country. The aim of NRHM was to ‘carry out necessary architectural correction in the basic health care delivery system’ (Government of India, 2005) mainly to improve access by strengthening health systems especially in the rural areas. There have been numerous studies on the NRHM, and while some argue that it may not have improved the situation like envisaged initially, it has led to improvements in parameters like immunization, institutional deliveries, and antenatal care (Hussain, 2011). Like most programs that are across the health sector, the NHM may have played a relatively greater role in national program priorities like disease control programs of the government. While
