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).
Table 4 presents the performance of BRICS nations in some of the key indicators related to public financing of health — total health expenditure in GDP, general government health expenditure in GDP, general government health expenditure in total health expenditure, and general government health expenditure in general government total expenditure.
Table 4:Public financing of health in BRICS.
Notes: THE: Total Health Expenditure, GGHE: General Government Health Expenditure, GGE: General Government Expenditure.
Source: Global Health Expenditure Database, World Health Organization.
The first aggregate gives the proportion of GDP spent on health and is inclusive of private health expenditure as well. South Africa and Brazil spend more than 8% of their GDP on health. While Brazil, China, India, and Russia have incrementally enhanced their health share of GDP over the 20 years, South Africa has been steadily spending around 8 percent during the same period. India spends less than 5% of its GDP on health and displays one of the lowest percentage point increase between 1995 and 2014.
How much do governments spend on health out of total income? For this, the second aggregate — general government health expenditure as a share of GDP — is useful, and it shows that South Africa spends the most with Brazil, Russia, and China following closely. India’s government spending on health is very low, around 1% of GDP. Governments of all the other BRICS nations spend more than double the amount as share of their respective GDP’s. The highest increase in the share of public expenditure on health between 1995 and 2014 happened in China, followed closely by Brazil. The lowest increase in this share was evident in the case of India, while in case of Russia the share actually declined.
This pattern is sharper when one looks at how much of the health spending is from government sources, the third column. All the countries, with the exception of India, spend almost half or more of their total health spending from government sources. Except Russia, all the nations increased their share of public finance in total health spending during the 20-year period. This is significant since in the nineties, close to three-fourths of health spending in Russia came from the government, way above the other BRICS nations. The biggest turnaround in this indicator appears to have happened for China, which saw a significant decline in the share of public spending in total health spending between 1995 and 2005, but thereafter increased by 17 percentage points between 2005 and 2014. Currently, China has the highest share of public spending in total health spending among BRICS, at 56%.
Finally, the last column shows how health is prioritized by Governments facing competing claims on its resources; general government health spending as a percentage of total government spending is highest in South Africa. This is followed by China and Russia and Brazil. Here again, India ranks low as it spends just 5% of its total government expenditure on health. However, for China and Brazil the share has declined from their 1995 levels.
Overall, the three indicators above indicate that China and Brazil have done consistently the best in terms of moving towards UHC, especially if one considers the changes in terms of public spending on health in the recent past. Russia and South Africa are also not doing too badly and often have interchanging places in the rankings among these five countries. However, the gap between the performance of these countries and that of India is often quite stark when we look at the body of evidence presented.
Enabling Environment: Governance and Reforms
Governance
There are two important angles to the UHC process that are often overlooked, one more than the other. These are reforms and governance. While reforms are often talked about, there are few studies that have looked at the comparative picture of reforms in the health sector in countries to see why countries have such uneven records in terms of progress towards universal access. We deliberately mention health sector reforms rather than reforms for UHC, because to achieve good outcomes in the health sector requires much more than merely putting in place UHC systems. In fact, for UHC to work, one needs a series of incremental reforms — big or small — happening steadily over time.
Mere allocation of public resources does not always yield the desired outcomes. This is primarily due to the quality of governance, a concept that is elusive and, therefore its measurement, very often subjective. An indistinct relationship between public spending and outcome is often related to the aspect of governance (Pritchett, 1996). There have been a number of studies linking overall governance performance with health outcomes. Some studies (Kaufmann et al., 1999, 2004; Gupta et al., 1999) have found governance indicators like voice and accountability, political stability and violence, government effectiveness, regulatory burden, rule of law, and graft to be significantly negatively related to infant mortality. Also, investment patterns have been seen to change with significant corruption, with investments being disproportionately more on physical infrastructure rather than health and education (De la Croix and Delavallade, 2006). Other studies show that greater citizen participation and better governance can lead to greater efficacy in government action in general (Isham et al., 1997). Also, political commitment, higher tax revenues, and greater democracy are associated with a higher share of GDP going