102474 Policy & practice Progress towards universal health coverage in BRICS: translating economic growth into better health Krishna D Rao,a Varduhi Petrosyan,b Edson Correia Araujoc & Diane McIntyred Abstract Brazil, the Russian Federation, India, China and South Africa – the countries known as BRICS – represent some of the world’s fastest growing large economies and nearly 40% of the world’s population. Over the last two decades, BRICS have undertaken health-system reforms to make progress towards universal health coverage. This paper discusses three key aspects of these reforms: the role of government in financing health; the underlying motivation behind the reforms; and the value of the lessons learnt for non-BRICS countries. Although national governments have played a prominent role in the reforms, private financing constitutes a major share of health spending in BRICS. There is a reliance on direct expenditures in China and India and a substantial presence of private insurance in Brazil and South Africa. The Brazilian health reforms resulted from a political movement that made health a constitutional right, whereas those in China, India, the Russian Federation and South Africa were an attempt to improve the performance of the public system and reduce inequities in access. The move towards universal health coverage has been slow. In China and India, the reforms have not adequately addressed the issue of out-of-pocket payments. Negotiations between national and subnational entities have often been challenging but Brazil has been able to achieve good coordination between federal and state entities via a constitutional delineation of responsibility. In the Russian Federation, poor coordination has led to the fragmented pooling and inefficient use of resources. In mixed health systems it is essential to harness both public and private sector resources. Introduction Reforms and health spending Brazil, the Russian Federation, India, China and South The five countries represented by the BRICS acronym are Africa – the countries known as BRICS – represent some of diverse. They vary in their level of economic development. the world’s fastest growing large economies and nearly 40% For example, the per capita gross domestic product of the of the world’s population.1 These five nations face several Russian Federation is approximately sevenfold higher than common health challenges: burdens from communicable that of India.1 Although the health reforms of BRICS are also and noncommunicable diseases, inequitable access to health diverse – especially in terms of the health-system issues that services, growing health-care costs, substantial private they have attempted to correct – they share a central and com- spending on health care, and large private health sectors. mon aim: the strengthening of the government’s role in health Over the last two decades, BRICS have undertaken – or and, particularly, in financing health care. have committed to – substantial health-system reforms that In Brazil, the Unified Health System – the Sistema Único have been designed to improve equity in service use, quality de Saúde – is a single publicly funded system that covers the and financial protection, with the ultimate goal of achieving whole population and is financed through general taxation. universal health coverage. These health reforms represent an Health services are free at the point of use. By constitutional important attempt to translate the growing wealth of BRICS sanction, each level of government has to earmark a minimum into better health. portion of its revenues for health.3 BRICS have adopted different paths to universal health Reforms in the Russian Federation established a system of coverage and they began travelling along those paths at dif- mandatory health insurance. In this system, payroll taxation is ferent points in time. Brazil and the Russian Federation used as a complementary source of funding for a health sector embarked on this process over two decades ago.2–5 China and that is predominantly financed through general taxes. Funds India are relatively new entrants, having started their reforms from payroll taxes are pooled by subnational insurance schemes in the last decade,6,7 and South Africa has only recently begun and health services are purchased via insurance companies.4,5 the reform process.8 In this paper, we begin by examining The Indian reforms strengthened the government’s role in the current state of health-care financing in BRICS and then health by increasing the funding of the public sector – via the move on to the underlying motivation behind the reforms and National Rural Health Mission, with a focus on primary care the lessons that BRICS’ experience holds for other low- and – and by establishing government-sponsored insurance for middle-income countries that are embarking on the path to the poor.6 The government insurance schemes cover hospital universal health coverage. care at empanelled public and private hospitals for the poor.9 a Public Health Foundation of India, ISID Campus, Vasant Kunj Institutional Area, New Delhi 110070, India. b American University of Armenia, School of Public Health, Yerevan, Armenia. c Health, Nutrition and Population, The World Bank, Washington, United States of America. d Health Economics Unit, University of Cape Town, Cape Town, South Africa. Correspondence to Krishna D Rao (e-mail: kd.rao@phfi.org). (Submitted: 28 November 2013 – Revised version received: 10 March 2014 – Accepted: 10 March 2014 ) Bull World Health Organ 2014;92:429–435 | doi: http://dx.doi.org/10.2471/BLT.13.127951 429 Policy & practice Translating economic growth into better health in BRICS Krishna D Rao et al. By creating an important role for Fig. 1. Government health spending and per capita gross domestic product, in Member the government in the health sector, the States of the World Health Organization, 2011 health reforms in China marked a sub- stantial departure from the old system of health care. One aim was to move 12 away from using patients as a source of financing.7 The reforms focused on 10 Government health spending (% of GDP) strengthening primary care services and increasing insurance coverage.10 South Africa’s National Health 8 Insurance Fund will be funded from Russian Federation taxes and – through active purchasing – should ensure that health services of 6 Brazil good quality are available to all citizens.8 China The Fund’s purchasing should enable the government to draw on human re- 4 sources located in both the public and private health sectors. 2 A predominant reliance on public financing is a necessary condition for South Africa India the achievement of universal health coverage.11 Health reforms have given 0 10 000 20 000 30 000 40 000 50 000 60 000 70 000 BRICS’ governments prominent roles Per capita GDP (US$) in the health sector, particularly in GDP: gross domestic product; US$: United States dollars. financing health care. However, private Source: World Health Organization.1 financing of health care – through private voluntary health insurance and Fig. 2. Government health spending, in Brazil, the Russian Federation, India, China and out-of-pocket payments – continues to South Africa (BRICS), 2011 represent a substantial share of health spending. In Brazil, China, India, the Russian Federation and South Africa, 80 Proportion of government expenditure attributed to health private financing accounts for 54%, Proportion of total health expenditure provided by government 44%, 69%, 40% and 52% of total health 70 spending, respectively.1 In comparison with other countries 60 with similar income levels, government spending on health as a proportion of 50 Expenditure (%) gross domestic product is relatively low in China (2.9%), India (1.0%) and the Russian Federation (3.7%), but it is 40 higher in Brazil (4.3%) and South Africa (4.1%) (Fig. 1). The entire population of 30 a country that spends at least 5–6% of its gross domestic product on health often 20 has access to basic health services – be- cause such a country is able to subsidize 10 health care for the poor sufficiently.12 All BRICS countries – particularly China 0 and India – have a distance to go in Brazil Russian Federation India China South Africa terms of achieving this spending bench- mark (Fig. 1) and ensuring adequate and Source: World Health Organization.1 sustained government financing for the reform process. (Fig. 2), than many countries in the Or- vate providers, for outpatient visits.14 In each BRICS country, health- ganisation for Economic Co-operation The government-sponsored insurance system reforms have been “flagship pro- and Development.1 There remains con- schemes remain focused entirely on grammes” for the national government. siderable potential for expanding health’s hospital care. Despite new investments However, such prominence has not nec- share of the governmental budgets in all in public primary care, many outpatients essarily translated into health becoming five of the BRICS countries. have been kept away from the public sec- more of a priority for the governments’ In India, out-of-pocket payments tor – and its promise of low cost health policy-makers. As a proportion of total still account for a very large share, care – by inadequate coverage and a government spending, BRICS still spend 59–71% of total health spending. 1,13 common belief that the private sector markedly less on health, 8.1–12.7% Most such payments are made to pri- offers better quality. 430 Bull World Health Organ 2014;92:429–435| doi: http://dx.doi.org/10.2471/BLT.13.127951 Policy & practice Krishna D Rao et al. Translating economic growth into better health in BRICS In China, out-of-pocket payments was largely driven by civil society rather Health Mission.6,21 A National Urban still represent 34% of total health than by the government, political parties Health Mission has also been intro- spending,1 partly because coinsurance or international organizations.2 Civil so- duced.21 In parallel, national and several schemes – that cover only a proportion ciety demanded a health system that was state governments have been system- of the costs of health care – are common responsive to – and controlled by – the atically and independently building a and partly because many workers in the public. It also demanded that health be government-sponsored health insurance informal sector have no health insur- considered a fundamental right. These system to cover the costs of secondary ance. 10 The failure of Chinese health values were reflected in the constitution and tertiary hospital care for the poor.9 reforms to make substantial changes to adopted in 1988, which paved the way The state-level schemes of health insur- existing provider-payment methods and for far-reaching reforms of the health ance were born as populist measures and the behavioural legacy of the previous 30 system and formally established the Uni- were closely associated with the political years – including the “public-for-profit” fied Health System – a system that was party that introduced them.9 mindset of many providers – have not based on the principals of universality, Although China’s transition from a only enabled out-of-pocket payments to integration and social participation.3 planned economy to a market economy persist but also encouraged providers to There was widespread political has created great economic growth, it escalate their charges.15 upheaval following the collapse of the has also had undesirable effects on the In Brazil, the levels of out-of- Soviet Union in 1991. There was univer- health sector.22 In 2009 China began pocket payments for health have fallen sal health coverage in the Soviet health reforming its health sector in response under the Unified Health System – to system – all citizens were entitled to to public concerns over the high cost of about 31% of total health spending. 1 health services and complete financial health care, the growing impoverish- In both Brazil and the Russian Federa- risk protection – but such coverage col- ment experienced by households as a tion, rising affluence and the perceived lapsed with the break-up of the Soviet result of health spending, and the large poor quality of public services – that Union.4,5 The early post-Soviet health health inequalities observed between are often inadequately funded – have reforms of the 1990s introduced man- provinces and between urban and ru- contributed to increased demand for datory health insurance to strengthen ral areas.7,23 These problems could be private voluntary insurance. In Brazil, the existing tax-funded health system attributed to the way in which health for example, private health insurance and provide universal access and com- services had been financed. For example, has grown to cover around 25% of the prehensive coverage. 4,16,17 Universal health insurance was far from universal population.2 In the Russian Federation, health coverage is now guaranteed in the in China. Even by 2002, only about half voluntary health insurance – which now Russian Federation, as a constitutional of the urban population and 90% of the covers 5% of the population and 3.9% right. Mandatory health insurance cov- rural population had insurance cover- of total health spending – has become ers almost all outpatient and inpatient age. 7 Although health facilities were six times more common over the last services while the government health publicly owned, the health providers decade.16 Such insurance may be compli- budget covers emergency, specialized in those facilities had to raise most of mentary to mandatory insurance – only and tertiary care and medication for cer- their own revenue – and patients were covering services provided in private tain vulnerable groups and conditions.16 a natural source of revenue. Moreover, facilities and outpatient medication – or Recent health-system reforms in collusion between providers and phar- supplementary – with a benefits pack- China, India and South Africa were maceutical companies helped to drive age that overlaps that of the mandatory broadly motivated by concerns over up the costs of health care.7 The reforms insurance and covers various informal the performance of the national health made in 2009 sought to give the Chinese payments, including those for inpatient systems, poor health outcomes and government a major role in the health care.16 While the percentage of the South persistent and large health inequities. sector, inject substantial public funds African population covered by private In India’s case, several factors led to the to increase insurance coverage, reduce insurance schemes has only increased onset of reforms. The existing public sec- fees-for-service and strengthen primary marginally over the last decade, there tor system – which had been expected care services.7,23 have been rapid increases in expenditure to be a vehicle for delivering low-cost Concerns over inequity in the within such schemes – driven by spiral- health care to all Indians – had failed health sector are also driving South ling provider fees. to deliver on its promise because it was Africa’s efforts to reform its health underfunded, undersupplied and under- system. The burden posed by human staffed.18 Not surprisingly, out-of-pocket immunodeficiency virus, tuberculosis, Different origins and payments to private providers and rising other communicable diseases, non- perceptions medical costs had placed a large burden communicable diseases and injuries on poor households and become an im- has disproportionately affected South The health reforms for the promotion portant cause of impoverishment.19,20 In Africa’s lower socioeconomic groups.24,25 of universal health coverage in the five addition, the fall of the incumbent gov- Only 17% of the population is covered BRICS countries were born of differing ernment in the 2004 election signalled – by private health insurance – leaving motivations and underlying causes. In to the new government – the importance the majority of the population reliant Brazil in the mid-1980s, almost 30 years of fundamental issues such as health.21 on tax-funded health services.26 Since of military dictatorship gave birth to In 2005, such concerns motivated the private health insurance accounts for a broad-based political movement for national government’s efforts to reform almost half (43%) of total health spend- re-democratization and improved social health care in the public sector, via the ing, there is far greater resourcing of rights. Health-sector reform in Brazil establishment of the National Rural services – on a per capita basis – for the Bull World Health Organ 2014;92:429–435| doi: http://dx.doi.org/10.2471/BLT.13.127951 431 Policy & practice Translating economic growth into better health in BRICS Krishna D Rao et al. minority covered by such insurance than countries have enjoyed several decades Federation faces considerable challenges for the majority of South Africans.26 The of high economic growth, they are cur- in negotiating its federal and subnation- South African constitution now requires rently having an economic downturn al structures. The rapid decentralization the government to make the necessary that may well have a detrimental effect of the 1990s created a complex situation resources available to realize the right on government health spending. The in which the Ministry of Health and to health and thereby address these economies of many other low- and Social Development, its federal agencies, disparities. To fulfil this constitutional middle-income countries have yet to regional and municipal health authori- obligation, the South African govern- experience a period of high growth. For ties and more than a 100 private health ment has committed to introducing a these countries, substantial increases -insurance companies share the respon- tax-funded National Health Insurance in government health spending seem sibility for the planning, regulation and Fund and moving towards universal unlikely, at least in the short-term. It is implementation of health reforms.4,5,16 health coverage.8 essential that such countries develop a There is also fragmented pooling of long-term plan to raise more resources health funds, between the federal and for health and use their health resources territorial governments. This makes it Lessons for reforms more efficiently.12 Health resources can difficult to implement any countrywide The five BRICS countries have followed be increased not only by giving greater reforms, leading to geographical varia- their own paths on the road to universal priority to health – in terms of its share tions, inefficiencies and inequity. South health coverage, with varying degrees of of government spending – but also by Africa also has a quasi-federal system success. However, their experiences offer increasing tax revenues. Importantly, as but with the responsibility for health some lessons for other low- and middle- in the case of Brazil and South Africa, split between national and provincial income countries that wish to pursue a declared constitutional right to health levels. It seems likely that South Africa universal health coverage. It has been care can ensure sustained government will, in the future, adopt a similar ap- the common experience of the BRICS financing of health reforms. Finally, gov- proach to health reform as currently countries that any movement towards ernance of the health sector often needs seen in Brazil. such coverage is slow and requires fun- strengthening to ensure that mandatory The health sector of many low- and damental problems in national health prepayment or public funding becomes middle-income countries is character- systems to be resolved. Despite more the main mechanism for financing ized by mixed health systems in which than two decades of reforms, the “early health services.12 both the public and private sectors pro- reformers” – Brazil and the Russian The administrative systems in many vide health services. Where the private Federation – still face fundamental low- and middle-income countries – sector for health-care delivery is large, challenges. Brazil, for instance, is yet like those in Brazil, India and the Rus- universal health coverage will depend to achieve complete coverage because sian Federation – entail a division of critically on the extent to which the it is difficult to attract qualified health power and responsibility between the resources within the private sector are workers in remote areas.27 In the Russian central government and subnational harnessed. In this situation, such cover- Federation, formal and informal out-of- entities such as states. Although they age is most likely to be achieved through pocket payments still create barriers to are made at the central level, national the strategic purchasing of services from accessing care for certain groups of the policies often have to be implemented both the public and private providers of population – even though the entire by subnational entities that are largely health care. Some BRICS countries have population is now covered by mandatory autonomous. This often leads to multiple attempted this type of purchasing. For health insurance and the state medical sources of fragmentation and much example, government-sponsored health benefit package. Moreover, the poor potential for the duplication of efforts insurance in India enables the purchase quality of some care, inequities in access and consequent inefficiencies. Brazil of hospital services from both public and to health care and the levels of prepay- has been fairly successful in managing private hospitals. South Africa’s National ment for health remain challenges in this problem. Its constitution delineates Health Insurance Fund also enables BRICS. Any future health reforms need the basic structure of the Unified Health the government to draw on human re- to address the root causes of these chal- System in terms of the decentralization sources located in both the public and lenges. Out-of-pocket payments for of the responsibility for the management private health sectors. Even in countries health care remain too high and too of health services to the subnational where the public sector dominates health common in several BRICS countries. levels of government. In India – where, financing and provision, such as Brazil In India’s case, payments for outpatient constitutionally, health is a state re- and the Russian Federation, growing care have been inadequately addressed sponsibility – central schemes such affluence has raised the population’s gen- by health reforms. In China’s case, the as the National Rural Health Mission eral expectations of the quality of health reforms have not adequately addressed offer funding to states to induce them care – leading to increased demand for the provision of adequate salaries for to follow the national reform’s vision. private health insurance. Such changes health-care professionals – resulting in In China, the central government sets may lead to a national health system that a continued reliance on payments from broad policy guidelines but leaves the is split, with the rich seeking care from patients. implementation details to local govern- the private sector while the poor must The five BRICS countries have had ments. In China and India, the centre rely on the public sector. varying degrees of success in substan- still has little administrative control over BRICS represent an unlikely group tially increasing government spending implementation and the quality of any of countries, which are diverse in so on health care, even in the presence of implementation can vary considerably many ways but united by their common high economic growth. While all five across subnational entities. The Russian experience of high economic growth and 432 Bull World Health Organ 2014;92:429–435| doi: http://dx.doi.org/10.2471/BLT.13.127951 Policy & practice Krishna D Rao et al. Translating economic growth into better health in BRICS an aspiration to improve the health of ability.11 For BRICS, the biggest chal- tional Health, Johns Hopkins University, their citizens. The motivations for recent lenge remains the effective translation of Baltimore, United States of America. health reform in each country differ and new wealth into better health. ■ each country has set out on its own – dif- Funding: DM is funded by the South Af- ferent – path towards universal health Acknowledgements rican Research Chairs’ Initiative of the coverage. Notably, all BRICS countries The authors would like to thank Joseph Department of Science and Technology have increased government spending on Kutzin (World Health Organization) and National Research Foundation of health and have provided subsidies for and Winnie Yip (University of Oxford) South Africa. the poor.11 However, such improvements for their valuable comments on the will not guarantee universal coverage in manuscript. KDR has a dual appoint- Competing interests: None declared. the absence of efficiency and account- ment with the Department of Interna- ‫ملخص‬ ‫ ترمجة النمو االقتصادي إىل صحة أفضل‬:)BRICS( ”‫التقدم املحرز صوب التغطية الصحية الشاملة يف جتمع “بريك‬ ‫وقد نتجت اإلصالحات الصحية يف الربازيل عن حركة سياسية‬ - ‫متثل الربازيل واالحتاد الرويس واهلند والصني وجنوب أفريقيا‬ ‫ يف حني كانت تلك اإلصالحات‬،‫جعلت الصحة حق ًا دستوري ًا‬ ‫ بعض االقتصادات‬- )BRICS( ”‫البلدان املعروفة بتجمع “بريك‬ ‫يف الصني واهلند واالحتاد الرويس وجنوب أفريقيا حماولة لتحسني‬ .‫ تقريب ًا من سكان العامل‬% 40‫الكربى األرسع نمو ًا يف العامل و‬ ‫ وقد اتسم التحرك‬.‫أداء النظام العام واحلد من التباينات يف اإلتاحة‬ )BRICS( ”‫ قام جتمع “بريك‬،‫وعىل مدار العقدين املنرصمني‬ ‫ ومل تعالج اإلصالحات يف‬.‫صوب التغطية الصحية الشاملة بالبطء‬ ‫بإجراء إصالحات عىل النظم الصحية للتقدم صوب التغطية‬ .‫الصني واهلند مسألة املدفوعات من اجليب اخلاص عىل نحو واف‬ ‫ وتناقش هذه الورقة ثالثة جوانب رئيسية هلذه‬.‫الصحية الشاملة‬ ‫وكانت املفاوضات بني الكيانات الوطنية ودون الوطنية صعبة يف‬ ‫ دور احلكومات يف متويل الصحة؛ والدافع‬:‫ هي‬،‫اإلصالحات‬ ‫كثري من األحيان غري أن الربازيل استطاعت حتقيق تنسيق جيد بني‬ ‫األسايس وراء اإلصالحات؛ وقيمة الدروس املستفادة للبلدان غري‬ ‫الكيانات الفيدرالية والكيانات عىل صعيد الواليات عن طريق‬ ‫ وعىل الرغم من الدور البارز‬.)BRICS( ”‫املنتمية إىل جتمع “بريك‬ ‫ أدى‬،‫ ويف االحتاد الرويس‬.‫حتديد املسؤولية بموجب الدستور‬ ‫ يشكل التمويل اخلاص‬،‫للحكومات الوطنية يف اإلصالحات‬ ‫سوء التنسيق إىل التشتت يف جتميع املوارد واالفتقار إىل الكفاءة‬ .)BRICS( ”‫حصة كبرية يف اإلنفاق الصحي يف جتمع “بريك‬ ‫ ومن الرضوري يف النظم الصحية املختلطة أن يتم‬.‫يف استخدامها‬ ‫ويوجد اعتامد عىل النفقات املبارشة يف الصني واهلند كام أن هناك‬ ..‫تسخري موارد القطاعني العام واخلاص عىل حد سواء‬ .‫تواجد ًا أساسي ًا للتأمني اخلاص يف الربازيل وجنوب أفريقيا‬ 摘要 金砖国家全民医疗覆盖的发展进程 ： 经济增长转化为更好的医疗状况 巴西、俄罗斯联邦、印度、中国和南非被称为金砖五 为宪法权利的政治运动，而中国、印度、俄联邦和南 国（BRICS），是全球发展最快的经济体，占将近 40% 非的改革则试图提高公共系统的绩效并减少可达性的 的世界人口。在过去二十年中，金砖国家着手卫生体 不平等。全民医疗覆盖之路推进缓慢。在中国和印度， 系改革，迈向全民医疗覆盖。本文讨论了这些改革的 改革尚未充分解决现金支付的问题。国家和地区实体 三个主要方面 ： 政府在卫生融资方面扮演的角色 ；改 之间的协商往往具有挑战性，但巴西通过宪法界定责 革背后的潜在动机 ； 以及所取得的经验教训对非金砖 任，已经能够实现联邦和州实体之间良好的协调。在 国家的价值。尽管各国政府在改革中起到重要的作用， 俄联邦，协调性差导致资源的分散统筹和低效利用。 但是民间融资构成金砖国家医疗支出的主要份额。中 在混合卫生体系中，充分利用公共和私营部门的资源 国和印度存在对直接财政支出的依赖，私人保险在巴 至关重要。 西和南非大量存在。巴西医疗改革源自一场让医疗成 Résumé Progrès vers la couverture de santé universelle dans le groupe BRICS: traduire la croissance économique en une meilleure santé Le Brésil, la Fédération de Russie, l’Inde, la Chine et l’Afrique du Sud – dans ces réformes, le financement privé constitue une part importante les pays connus sous le nom de BRICS – représentent quelques-unes des dépenses de santé dans le groupe BRICS. Il existe une dépendance des grandes économies ayant connu la croissance la plus rapide dans à l’égard des dépenses directes en Chine et en Inde et à l’égard d’une le monde et près de 40% de la population mondiale. Au cours des présence importante des assurances privées au Brésil et en Afrique du 2 dernières décennies, le groupe BRICS a engagé des réformes de son Sud. Les réformes de la santé du Brésil ont fait suite à un mouvement système de santé pour atteindre la couverture de santé universelle. politique qui a fait de la santé un droit constitutionnel, alors que les Cet article aborde les 3 aspects clés de ces réformes: le rôle du réformes en Chine, en Inde, en Fédération de Russie et en Afrique du gouvernement dans le financement de la santé; la motivation profonde Sud ont représenté des tentatives visant à améliorer la performance derrière ces réformes; et la valeur des leçons tirées pour les pays non- du système public et à réduire les inégalités de l’accès aux soins. Les BRICS. Bien que les gouvernements nationaux jouent un rôle majeur progrès vers la couverture de santé universelle ont été lents. En Chine Bull World Health Organ 2014;92:429–435| doi: http://dx.doi.org/10.2471/BLT.13.127951 433 Policy & practice Translating economic growth into better health in BRICS Krishna D Rao et al. et en Inde, les réformes n’ont pas abordé suffisamment le problème Dans la Fédération de Russie, le manque de coordination a entraîné un des paiements restants à charge. Les négociations entre les entités regroupement fragmenté et une utilisation inefficace des ressources. nationales et infranationales ont souvent été difficiles, mais le Brésil a Dans les systèmes de santé à financement mixte, il est essentiel de pu parvenir à une coordination adéquate entre les entités fédérales et maîtriser à la fois les ressources des 2 secteurs: public et privé. étatiques grâce à une délimitation constitutionnelle des responsabilités. Резюме Прогресс в достижении всеобщего медицинского обеспечения в странах БРИКС: трансформация экономического роста в улучшение здоровья населения Бразилия, Российская Федерация, Индия, Китай и Южная Африка конституционного права населения, в то время как в Китае, Индии, — страны, известные как БРИКС, — являются одними из самых Российской Федерации и Южной Африке они представляли быстрорастущих крупных экономик мира и составляют почти собой попытку улучшить эффективность государственной 40% населения земного шара. За последние два десятилетия системы здравоохранения и уменьшить неравенство в доступе страны БРИКС предприняли реформы систем здравоохранения к медицинских услугам. Переход к всеобщему медицинскому для улучшения всеобщего медицинского обеспечения. В данной обеспечению был медленным. Реформы в Китае и Индии статье обсуждаются три ключевых аспекта этих реформ: роль в недостаточной степени решали вопросы оплаты услуг государства в финансировании здравоохранения, мотивация, населением. В Бразилии зачастую было затруднительно достичь лежащая в основе реформ, и ценность извлеченных уроков для договоренности между центральными и территориальными стран, не входящих в БРИКС. Хотя национальные правительства субъектами, однако страна смогла добиться хорошей играют заметную роль в реформах, частное финансирование координации между федеральными и местными учреждениями продолжает составлять основную долю расходов на путем конституционного разграничения ответственности. В здравоохранение в странах БРИКС. Расчет строится на прямых Российской Федерации плохая координация программ привела затратах на здравоохранение в Индии и Китае и на значительном к фрагментации и неэффективному использованию ресурсов. присутствии частного страхования в Бразилии и Южной В смешанных системах здравоохранения важно использовать Африке. Бразильские реформы здравоохранения возникли в ресурсы как государственного, так и частного секторов. результате политического движения за охрану здоровья как Resumen El progreso hacia una cobertura sanitaria universal en los países BRICS: traducir el crecimiento económico en una mejor salud Brasil, la Federación de Rusia, India, China y Sudáfrica, los países resultado un movimiento político que hizo de la salud un derecho conocidos como BRICS, son algunas de las grandes economías que constitucional, mientras que las de China, India, la Federación de Rusia más rápidamente están creciendo y representan casi el 40% de la y Sudáfrica fueron un intento de mejorar el rendimiento del sistema población mundial. A lo largo de las últimas dos décadas, los BRICS público y reducir las desigualdades del acceso a este. El avance hacia han emprendido reformas en los sistemas sanitarios para avanzar hacia la cobertura universal de la salud ha sido lento. En China e India, las una cobertura universal de salud. Este artículo analiza tres aspectos reformas no han abordado adecuadamente el problema de los pagos clave de estas reformas: el papel del gobierno a la hora de financiar directos. A menudo, las negociaciones entre las entidades nacionales la salud, los motivos subyacentes de las reformas y el valor de las y subnacionales han sido difíciles, pero Brasil ha sido capaz de lograr lecciones aprendidas de otros países distintos a los BRICS. Aunque los una buena coordinación entre las entidades federales y estatales a gobiernos nacionales tienen un papel destacado en las reformas, la través de una descripción constitucional de la responsabilidad. En la financiación privada constituye una parte importante de los gastos Federación de Rusia, una mala coordinación ha tenido como resultado sanitarios en estos países. Hay una dependencia de los gastos directos una mancomunación fragmentada y el uso ineficaz de los recursos. 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