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 child mortality rates 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