Reforms and emerging markets: increasing access to health

In pharmaphorum's emerging markets themed month, Ruben Gennero explores the healthcare systems in China, India and Latin America.

We all know that Health Systems are not a static structure. On the contrary, they are a dynamic entity shaped by the culture, political scenario and in the end, the different relations established among the citizens and in general the State. In other words, health systems along with the education could appear as the truly representation of the social contract established within the country.

In such context, the main milestones which allow us to understand the evolution of the health systems are the reforms, where it is possible to observe the scope of the changes and political purposes behind them. In that regard, there is one part of the world which has been heavily involved trying to figure out how to improve the healthcare experience during the past years, which is the so called emerging world.

"India has embarked on a series of reforms aiming to increase spending, coverage and quality of its overwhelmed health system"

China has been a good representative of such matter. A decade ago there was little health insurance, either public or private, and healthcare costs were a common nightmare for many people in China. In 2009, after a failed attempt to increase the competition within the system, the Chinese government speeded up a package of reforms aiming to make more accessible and affordable the Chinese Healthcare system. The results are evident, with at least 95% of the population covered by some kind of health insurance, covering at least half of the total expenditure once they are admitted in the hospital. The expansion of the enrolled population has had a direct consequence, which has been the need of increasing the government's share of health spending, from 16% in 2001 to 30% in 2011 according to the data published.

But despite the investment, still the perception regarding the level of responsiveness, in both quality of care and accessibility, is not that good. The still high out of pocket expenditure (an average of 50%) and the incentives imposed over the Hospitals are diverting the attention from the elderly to the younger, where the profile of the disease is shorter (and cheaper) compared to the population over 60 years old. In addition, the decrease in the availability of drugs (even the lowest priced) in both, the public and private sector, despite the National Essential Medicine Policy has increased the feeling of lack of protection.

Further west, another big power is facing a huge challenge in terms of health and the need of reforms. Since 2011, India has embarked on a series of reforms aiming to increase spending, coverage and quality of its overwhelmed health system, clearly understanding that there is a positive correlation between the health state of the population and country development. In fact, India has one of the smallest investments in healthcare in terms of percentage of GDP, which is definitely a non-compatible situation with a country that aspire (or already is) a world power.

"India has one of the smallest investments in healthcare in terms of percentage of GDP"

In India, one of the main goals amongst the changes proposed is to obtain universal health coverage by 2022. In fact, in November 2011 a High level Expert Group submitted a report to planning commission on Universal Health by that date. Furthermore, the recommendations for such goals pertain to different areas such as health financing, infrastructure, health services norms, human resources, access to medicines and indeed, community participation.

However, according to an analysis published by the Indian Journal of Community Medicine (Singh Z.), India do face "an enormous challenge to achieve such goal due to the high disease prevalence, the fragmented and unregulated healthcare delivery system, inadequate finances and various political pull and push of different forces. In addition, the author point out that in the absence of sustained financial support, strong political will and leadership, dedicated involvement of all stakeholders and community participation, attainment of Universal Health Coverage "will remain a utopia"."

And what about Brazil, a country which is definitely on the spot during these years, not only for its huge market (over 200 million people ) or the World Cup (I can't wait for July!), but the very attractive growth figures, particularly during the past years. With a National Health System (Sistema Unico de Saude-SUS) already in place and one of the smallest level of out of pocket spending in the region (totally the opposite from the other big player in the Latin American Region, Mexico), Brazilian politicians and administrators are struggling in terms of how to enhance the performance of the heavily fragmented health provision in several states, each one of them acting as an isolated region. Despite the efforts in order to standardize practices and guidelines (Conitec, the Brazilian Health Technology Assessment agency is one example), still the SUS reform needs a better shape in aggregated terms. That's quite a challenge in a country as big and diverse as Brazil.

"Brazilian politicians and administrators are struggling in terms of how to enhance the performance of the heavily fragmented health provision in several states..."

Finally, some words for Mexico, the second most important market of Latin American region and the country which aspires to become the new Brazil, thanks to its booming economy, which is performing well in this time due to a series of political and economic reforms that the executive power is carrying out. On the Healthcare front, one decade ago almost 40% of the population did not have financial protection, over the past 10 years Mexico has been attempting to achieve the goal of universal coverage. Now, with the Popular's Insurance policy (Seguro Popular) almost 90% of Mexicans are enrolled either in the Seguro Popular or one of the social security subsystems. The next challenge for Mexico is to keep integrating the operation of the system and leave behind the differences amongst the different providers, such as IMSS, ISSSTE , PEMEX, etc.

As we note, the health systems in the emerging world are evolving. A common aspect is the need for achieving universal coverage, particularly in the east, as well as the need for unifying the operation of the fragmented health provision. One thing is for certain, the emerging world has quite a lot of work to do...