Fit for purpose universal heathcare

Universal healthcare

High-growth countries face a challenge to maintain a healthy middle class

the developing world, is to keep people out of hospital. The key to
doing it properly is to have the state taking overall responsibility for
constructing and funding a health system while imposing regulations
and controls to hold costs in check, including for the supply of drugs
and other essential medication.
Standards of delivery are also in the spotlight. According to World
Health Organization (WHO) criteria, good primary care is defined as
family- and community-oriented care, provided by the same local
doctor and covering all health conditions. Although timeliness of
access is only loosely defined, doctors are meant to be available for
house calls. In most parts of the world, this remains an aspiration.

Olympian effort

V

ast swathes of the world are emerging from grinding poverty
and are shifting their focus from subsistence to consumption.
By 2020 almost one in three citizens of the world’s fast-growing
developing countries will be categorised as middle-class. That figure
will rise to 50% by 2030, according to Boston Consulting Group, a USbased management consulting firm.
While there is no standard definition of “middle class”—a few
international agencies argue that those earning only a few US dollars
a day can still be counted as middle-class—these new consumers are
generally buying more cars, washing machines and mobile phones; they
have access to higher standards of education and are having smaller
families. This emerging middle class is also developing a variety of other

tastes, aspirations and demands—particularly in healthcare.
Meeting this wave of expectation is creating a challenge that governments
are struggling to meet. Many developing countries do have first-world
healthcare facilities, but they are often only available to a small minority
who can afford substantial insurance. For the rest, critical illness can
bankrupt whole families and throw them back into destitution.
Babulal Sethia, president elect of the Royal Society of Medicine in
London, is a cardiologist who has spent much of his career setting up
healthcare services in the developing world. He says the accepted rule
of thumb is that if individuals have to bear more than 20% of healthcare
costs out of their own pocket, then any serious illness is financially
catastrophic: “People need to be able to access healthcare, but not in a
way that means they subsequently can’t eat.”
Thus the aim of primary care, recognised by healthcare systems across

SPONSORED BY:

In Brazil, more than one-third of the population is already defined as
middle-class. The world’s seventh-largest economy, according to the
World Bank, has made substantial headway with its ten-year-old “Bolsa
Família”— a scheme to lift families out of absolute poverty through
grants of financial aid. Meanwhile, its attempt at a universal primary
care service is much admired.
But this expanding middle class is now increasingly suffering the ill
health associated with affluence, as experienced in other parts of
the developing world. Rates of non-communicable conditions—heart
disease, stroke, diabetes, dementia and arthritis—are spiralling.
“The healthcare initiatives taken so far in Brazil have not really
addressed the problems of the middle classes,” says Andy Haines,
professor of public health and primary care at the London School of

Hygiene and Tropical Medicine, who has spent much of his career as a
WHO adviser. “There is a problem not only of a shortage of doctors, but
also many of them are poor quality and not properly trained,”according
to Mr Haines.
The challenge will be getting the skilled medical staff to scale up
primary care in order to keep overall healthcare costs sustainable.
Doctors are now being imported from abroad to meet Brazil’s shortfall,
although the best candidates continue to opt for lucrative jobs in city
private hospitals.
China continues to have by far the fastest-growing middle-class
population. Despite persistent tight government involvement in most
aspects of the economy, state control over the provision of healthcare
has until now been remarkable by its absence.
The Chinese habit of saving money will continue to keep a lid on
consumer spending, according to a Euromonitor report on the emerging


middle classes published in November 2013. Yet that tradition will
not be enough to help families cope with escalating medical bills in
the unregulated healthcare market. True, many hospitals are statecontrolled and ostensibly free, but drugs, scans and all other medical
services are extras that can lead to significant individual costs.
Now an experiment is under way in two areas of Beijing. It is based on
the UK’s National Health Service (NHS) model of using primary care
doctors as healthcare “gatekeepers” to keep people out of hospital. The
trial, covering a population of 4m people defined as urban, relatively
affluent and middle-class, requires users to pay a flat annual insurance
premium of Rmb600 (US$96), which includes unlimited access to
primary care and a list of 200 low-priced basic drugs.
The ceiling on hospital care costs is set at six times the average annual
income—still crippling for many people who do not have additional

insurance. Even so, Jin Xu, a PhD student being funded by the Chinese
government to assess the scheme, says the hope is that strong primary
care will stabilise and contain demand. “This project is part of a national
agenda to address the problem of [controlling] healthcare demand,”
he says. “If it is successful, the plan is to extend it to more areas.”

Faster, higher, stronger
It is widely recognised that economic progress depends on healthcare.
India, another so-called BRIC country alongside Brazil, China and
Russia, is suffering from a total lack of central healthcare planning.
Many commentators fear that this deficiency may hold back its growth.
Beyond the BRICs, other high-growth countries are making progress
here.
Although the devastation wrought in the Philippines by Typhoon
Haiyan will undoubtedly be a setback, the country has begun to invest
seriously in a centrally operated scheme to provide for the healthcare
of its newly affluent population. Vietnam is also making similar efforts.
The emerging economies that can get this formula right will ultimately
consolidate their position as members of the global middle class.