et al., 2010). Differences in the efficacy of public spending have been attributed to mainly the quality of governance, with better health outcomes from public spending reported from countries with better governance (Rajkumar and Swaroop, 2008). WHO defines governance in the health sector to mean “a wide range of steering and rule-making related functions carried out by governments/decisions makers as they seek to achieve national health policy objectives that are conducive to UHC”.4
Figure 4:Governance Index.
Notes: 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: Raw indicators (World Development Indicators, Transparency International).
The idea of ‘governance’ ranges from a simple statist interpretation that governance is what governments do, to a much wider interpretation of governance as the way in which individuals, groups, and institutions, both public and private, manage their affairs and resolve conflicts of interest in an orderly manner (Weiss, 2000; DARPP, 2009; Shome, 2012). In this work, we adopt a mixed interpretation of governance whereby good governance pertains to (1) delivery of services (banks, electricity, water, sanitation, physicians, and teachers) of good quality and (2) general governance indicators (ease of doing business, corruption, unemployment, gender equality, and sustainability). We constructed an index for governance based on 11 selected indicators representing these aspects (Figure 4).
China appears to be the best governed country, while India lies at the bottom, with a substantial difference in their respective governance indices. Overall, China, Russia, and Brazil seem to have better governance indicators in the group.
These findings are consistent with findings on progress towards UHC, especially if one notes that South Africa spends substantially on public financing on health but has not made similar progress on some of the other indicators of UHC, indicating the possibility of governance playing a role — one would expect health spending to be more efficient in the better governed countries generally. While no firm conclusions can be drawn from such a small sample size, it does seem to confirm that better governance and better health coverage would probably go together.
The indicators of governance and performance of these countries on each of them is given in Table A.1.
Health Sector Reforms
The most important piece of the puzzle is the role played by reforms in the health sector, specific to UHC or otherwise. We analyze the role of reforms in each of the countries in this section.
Brazil
Prior to 1988, social security institutions, especially the National Institute for Social Medical Assistance (INAMPS), formed the cornerstone of the health system. In 1988, the new constitution of the country established health as a fundamental right and duty of the state, which started a process of health system reform which was spread over many years. However, the process of reforms can be said to have started somewhat earlier though not in such fundamental form. Brazil’s health coverage was run on a model of social security based on compulsory contributions by employers and employees, leaving a large section of informal and agricultural sector workers uncovered until the 1970s, when it was expanded to include particular services (Elias and Cohn, 2003). It has been argued that the movement for Brazilian health reform involved various segments of society right from the middle of the 1970s, and principles of universality and equality formed the basis of much of the discourse on reforms (Gragnolati et al., 2013). With the constitutional reform, the Unified Health System (SUS) was set up and many administrative and organization changes were effected in the health system in the subsequent years, including a significant expansion of capacity of the system, decentralization for service delivery, measures to address regional disparities among others. The Family Health Program or the FHS is a key part of the national Unified Health System funded primarily through taxes, and it offers free primary care to a majority of Brazilians. It is a cornerstone of the public health delivery system in the country (Bulletin of the World Health Organization, 2008). In addition to the SUS, the country has the Complementary Medical Care System or the SSAM, which caters to a limited segment of the population.
According to a World Bank assessment, one of the major accomplishments of the SUS has been to unify and integrate several independent systems of financing and service provision into a single publicly funded system covering the whole population (Gragnolati et al., 2013). Also, all three tiers of the government — federal, state, and municipal — have participated in the reforms, making the vision of reforms quite a unified one.
There are some issues that remain critical in the Brazilian health system. There are distributional access issues mirroring socioeconomic determinants of health, and inequity in access remains a critical area of concern. While public financing seem high compared to some of the other BRICS countries, funding has remained a challenge, and Brazil’s share of public spending in GDP has remained somewhat low, placing Brazil far below the OECD average for government share of health expenditures (Macinko and Harris, 2015). This is surely going to impact a faster pace of UHC due to the rapidly rising NCDs. Also, the rapid expansion of the FHS has led to a physician shortage, resulting in the controversial Mais Médicos (More Doctors) program (PAHO, 2015) which involved importing doctors from other countries. This has resulted in quality concerns. The quality of health services and inputs are deemed quite uneven at the municipal levels. Also, the non-poor often prefer to seek services in the private sector due to overcrowding and waiting time, though they also visit the public sector to get costly treatments, again leaving the poor to use the SUS (Khazan, 2014).
Despite these challenges, Brazil is an example of a country that has carried out incremental reforms in the health sector and has shown sincerity in course correction over the years. The second feature of the Brazilian reforms is the earnest engagement of a wider network of stakeholders and civil society, who took — and continue to take — an active interest in reforms. For example, there have been public protests regarding the need for greater public investment in health care, which could have partially triggered the launch of its pay-for-performance scheme within the FHS (Macinko and Harris, 2015), one of the largest such schemes in the world. Also, by design, FHS is run with community participation and, therefore, is truly based on community participation.
Finally, evidence-based policymaking is another feature of the Brazilian system which has helped it continually evolve and make changes, resulting in course corrections as and when required (Elias and Cohn, 2003).
China
China’s success in UHC has been hailed as extraordinary, and China has been the focus of many studies since it started its reform process in 2009 (Yip et al., 2012; Yu, 2015), when it announced its Health Care System Reform. The Implementation Plan for the Recent Priorities of the Health Care System Reform visualized the provision of affordable medical care for all its citizens by 2020.5 The reform envisaged a complete overhaul of China’s healthcare system, and addressed all aspects of the health system. Particular focus was given to the grassroots medical networks, infrastructure, personnel, hospital reforms, and drugs and medicines.
Earlier, China had a well-performing system of rural health care, and the Rural Cooperative Medical Schemes (RCMS) was seen as a success. Social insurance and barefoot doctors made the rural health system a sturdy one (Wan and Wan, 2010). However, the move towards market economy resulted in major reversals and the system witnessed high OOPS, stemming mainly from the government’s omission to address the health system while it transited to a market economy (Yip et al., 2012).
Currently, China operates a three-level medical service system: national level, province level, and county level. It has three main