Gupta* and Samik Chowdhury†
*Health Policy Research Unit, Institute of Economic Growth, Delhi, India
† Ambedkar University, New Delhi, India
Introduction
Universal Health Coverage (UHC) has been a major topic of discussion and debate in the recent past globally, especially since the passage of a UN General Assembly resolution on UHC in December 2012.1 While global organizations such as the WHO and the World Bank have defined UHC, it is still not apparent whether all countries interpret UHC in a similar fashion. It has been argued that UHC has been labeled in a variety of ways and implemented based on the interpretation by countries, indicating the need for a global operational definition (O’Connell, 2014). Evidence does exist, however, to indicate that broader health coverage generally leads to improved health, especially for the poor via better access to services (Rodrigo and Smith, 2012).
The first Global Monitoring Report on Tracking UHC, brought out jointly by WHO and the World Bank,2 defines UHC thus: all people receiving the health services they need, including health initiatives designed to promote better health (such as anti-tobacco policies), prevent illness (such as vaccinations), and to provide treatment, rehabilitation, and palliative care (such as end-of-life care) of sufficient quality to be effective, while at the same time ensuring that the use of these services does not expose the user to financial hardship. The Sustainable Development Goals (SDGs) also contain a specific goal for UHC, making progress towards UHC a global as well national imperative.
Over the last decade or more, India has also been articulate about the country’s need to have UHC. However, the recent history of the country’s attempt at greater health coverage raises the issues of interpretation of UHC specifically, as well as prioritization of health in general. The BRICS countries as a whole are not necessarily the best examples of how UHC is to be implemented. The group is small, the economic and political situations are somewhat different, and the experiences are diverse. Nevertheless, this diversity of experiences is possibly sufficient to understand the “do’s and don’ts” in the path to UHC, and would contain important lessons for India. There are earlier analyses on this subject as well where a slightly different set of indicators have been used to look at the progress towards UHC (Marten et al., 2014). We aim to expand the analysis substantially with more recent data and also use a slightly different approach to understand where India’s position vis-à-vis the other BRICS countries in the context of UHC.
We start by laying out a framework to understand how one might measure progress towards UHC in the second section. In the third section, we look at the health status and disease profile in these countries, which is important to understand priorities within any UHC package. In the fourth section, we look at selected indicators discussed in first section to understand the countries’ progress towards UHC. Fifth and sixth sections analyze governance and health reforms, respectively. In the last section, we present our conclusions based on the analysis on how countries have fared and what India might take away as valuable lessons from these varied experiences.
Understanding UHC in BRICS Countries: A Framework
The World Health Report of 2010 (Evans and Etienne, 2010) laid out a simple list of three questions that countries need to take into account 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