and/or catastrophic expenses that in many instances forces them into greater poverty, or essentially costs them out of insurance coverage and healthcare altogether. Therefore, as I explain in greater detail shortly, to ensure that government spending avoids this issue and continues to reduce inequality, governments should either completely subsidize health insurance for all or focus on investing more resources into the public health sector. As the cases of India, China, and more recently Indonesia illustrated, an increase in government spending for public health systems and publically-funded national health insurance programs has been associated with gradual improvements in economic inequality. In all of these nations, income and consumption inequalities have gradually improved, with the rural poor seeing higher income and consumption levels. Increased spending in these nations has also been associated with general improvements in women’s access to healthcare, though more work is needed in this area. In Russia, however, government spending for the public health system and publically-funded national health insurance programs have continued to be insufficient and has not been associated with overall improvements in economic and gender inequality. Worse still, government spending is projected to decrease, which will make it harder to reduce inequality levels.
However, in all of these nations, more government spending is needed to provide additional healthcare infrastructure and human resources. Federal budgets must seek to allocate more funding to the states for the construction of hospitals and clinics, up-to-date medical machinery, as well as well-trained doctors, nurses, and healthcare workers. In India, China, Russia, and Indonesia, there are still ongoing geographic differences in access to better infrastructure and human resources, with urban areas having more resources compared to rural areas. Federal budgets should allocate more funding to address this geographic gap, which, in turn, can help to improve the overall quality and effectiveness of healthcare, reducing inequalities all the more. In this study, Indonesia has shown the greatest commitment to funding healthcare infrastructure; and yet, this has not corresponded with increased funding for human resources. Both infrastructure and human resources must be well financed in order to ensure access to quality healthcare and further reductions in inequality.
The importance of simultaneously financing these institutional reforms is also apparent when one examines publically-funded national health insurance programs, specifically those that are focused on financial protection among the poor. Although economic inequality through increased healthcare spending has gradually improved in India, China, and Indonesia, with the exception of Indonesia, recent publically-funded national health insurance programs targeting the poor still struggle to achieve their goal of avoiding out-of-pocket (OOP) and catastrophic expenses. Indonesia, in contrast, has seen a reduction in OOP and catastrophic expenses among the poor. Indonesia was the only government that increased central government oversight and the regulation of public and private hospital practices, ensuring that doctors do not overprescribe medications and health services that are unnecessary and expensive. Indonesia’s government has also adhered to financing both inpatient and outpatient services, carefully regulating if the Jamkesmas program is providing such funding. This study has also revealed the critical need for greater central government spending for locating and reaching out to the poor, as well as women, in order to inform them of their healthcare benefits, where they can go for treatment, while encouraging them to seek out care. To ensure an ongoing reduction in inequality, federal and state ministries of health need to fund local bureaucratic efforts to locate and inform the poor and women about where they can go for heath prevention and treatment services, while providing information about their healthcare rights. Healthcare workers must also meet with and encourage the poor and women to seek medical care, reassuring them that the state is there to serve their needs, to support them, and that there should be no shame in seeking care for ailments – especially those with a social stigma, such as HIV/AIDS and tuberculosis (TB). These outreach goals will be vital for ensuring not only better health outcomes, but also reducing inequalities in health and income between the rich and poor.
However, it is important to emphasize that increased federal and local government oversight and regulation of public and private hospital practices must occur prior to and during these state outreach efforts. Otherwise, even more of the poor could run the risk of experiencing OOP and catastrophic expenses.
The attainment of universal healthcare has been a goal that all of these nations have strived for. While access to a variety of publically-funded national health insurance programs have increased in India, China, Russia, and Indonesia, in some nations inequality persists in terms of the services that are covered. In India, health insurance for civil servants through the CGHS (Central Government Health Services) program covers all inpatient and outpatient services, while this is not the case for the poor through the voluntary RSBY program. Furthermore, CGHS reimbursement rates are not capped at a specified amount, while this is not the case for the RSBY program. In China, in 2010 the EUBMI insurance program for all urban unemployed provided 65% coverage, while the voluntary NCMS insurance program for the poor provided only 41%. In Indonesia, while fortunately the poor’s
Jamkesmas insurance program provides full coverage for all inpatient and outpatient services, sans reimbursement
caps, the BJPS system for formal sector workers does not provide coverage for critical long-term inpatient services, such as cancer treatment and cardiac surgeries. Russia is the only country that provides coverage for all inpatient and outpatient services for all insurance programs, though there are claims that beneficiaries often do not receive such benefits.
In the future, these nations will need to ensure that there is complete equality in terms of coverage and reimbursement rates for all healthcare services. Unless this is achieved, inequalities in insurance coverage and healthcare services will persist, notwithstanding ongoing increases in national spending to achieve universal coverage.
However, this raises a broader issue that needs to be addressed: that is, the difference between increased insurance coverage versus meaningful access to healthcare. That is, while more individuals may now have greater access to health insurance, this does not guarantee the attainment of health services. High co-payment fees and catastrophic expenses may limit the poor’s ability to participate in government-run health insurance programs that often entail either contractual partnerships with the private sector and/or caps on insurance coverage. Instead, what is more meaningful is health insurance that provides guaranteed access to healthcare, for everyone, without any kind of out of pocket contributions or reimbursement caps. Unfortunately, however, while India, China, and Russia’s governments have been dedicated to increasing access to publically-funded national health insurance, mainly through a patchwork of national-level programs targeting different segments of the population, these challenges have precluded the poor from obtaining access to healthcare, while deepening their poverty levels through ongoing out-of-pocket and catastrophic expenses.
In India, for example, in addition to the aforementioned challenges associated with targeted health insurance programs for the poor, e.g., RSBY, the government’s recent effort to provide universal health insurance coverage through the National Health Assurance Mission (NHAM) seeks to increase private sector participation in federal health insurance schemes. Under the NHAM, state governments will be encouraged to outsource much of their treatment services to private hospital providers (Kalra, 2014). However, this could further fuel the ongoing problem of co-payment fees, which in turn could lead to even greater costs for the poor, as well as the possibility of excessively high catastrophic expenses should some private providers refrain from covering services. To ensure meaningful access to healthcare, then, governments such as India and China should consider three options: first, eliminate the private sector’s role in providing contracted treatment services through publically- funded national health insurance programs; second, eliminate all co-payment user fees for these programs,
thus fully subsiding all inpatient and outpatient services at public as well as private hospitals; or third, strengthen the quality and coverage of a government-financed public health care system for all, as seen with the United Kingdom’s National Health Service (NHS) and Mexico’s Seguro Popular.
The overall goal through these options is to ensure that nobody, especially the poor, be exposed to the possibility of being forced to refrain from obtaining healthcare services and care due to additional individual costs required by health insurance schemes, even if they may be perceived as minimal. For instance, while a co-payment fee of £30 to £50 pounds a year may not seem high for the middle- and upper-income groups, it is still considered high among the poor and may, in turn, induce them to refrain from pursuing healthcare or confront increased financial burdens. Access to healthcare, if it is considered to be a human right, should not cost anything for the poor – or anyone for that matter.
In light of the ongoing limitations associated with publically-funded national health insurance programs, then, the best option is to invest more in the public health system. Thus far, with the exception of India’s Jamkesmas program targeting the poor (which, if you recall, is completely subsided by the central government), none of the publically-funded national health insurance programs in India, China, and Russia have ensured that the poor have complete access to healthcare; because of this, these nations should focus instead on strengthening the public health system, such as increased spending for fully subsidized prevention (especially primary care) and treatment services, while strengthening decentralization processes by providing federal grant assistance for improved hospital infrastructure, technology, and medical personnel - especially in rural areas.
Yet another policy issue that needs to be addressed is the ongoing challenge of discrimination towards women. In all of the nations examined in this report, women continue to be discriminated against, both socially and within households, while being victims of medical malfeasance. In India, for example, women have become victim to medical malpractice through the RSBY program, where doctors have performed unauthorized medical procedures in order to claim benefits through this insurance program. To help address these issues, all of these governments should increase spending to provide policy initiatives addressing discrimination, violence, and harm towards women; these initiatives could include, for example, federal and regional health officials closely regulating physicians’ activities, while working with hospitals and clinics to reach out to women, informing them of their healthcare rights, while meeting with community members and families to highlight the importance of women’s health.
However, women also continue to encounter difficulties with accessing meaningful healthcare. Returning to the issue of the barriers to accessing healthcare due to the presence of the private sector and high co-payment fees for publically-funded national health insurance programs, within households, it is women that often suffer the most from this situation. As seen in India and China (Mehrotra and Chand, 2012; China Daily, 2005; Song and Bian, 2014), this is because household heads, typically men, control the family budget and prioritize healthcare spending for male over female family members, while making women dependent on male household heads for financial support (ibid). This problem is further compounded by the fact that women generally earn less pay then men. In this context, women continue to experience the greatest hardship in accessing health care.
But what factors have contributed to an increase in government spending for public health systems and publically-funded national health insurance programs and what can we learn from these emerging economies? First, in India, China, and Indonesia, it seems that this spending has been prompted by a realization that providing effective healthcare services is vital for ensuring individual prosperity and, therefore, economic growth
and prosperity. While India and China’s political leaders may not be the most receptive to civil societal pressures for increased spending, and while spending is still not yet a priority policy focus, political interest and commitment to spending appears to be improving; this is critical for heath spending’s ongoing positive association with reduced inequality.
The case of Indonesia appears to provide the best example of how a sudden change in political institutional design and commitments to the public health system and publically- funded national health insurance spending can be associated with a reduction in inequality. While Indonesia’s presidents were not entirely committed to such spending during the early- 2000s, despite worsening inequality levels, by 2009 the President, Susilo Bambang Yudhoyono, began to emphasize and campaign on the importance of providing effective healthcare, especially for the poor. That same year, the constitution was reformed, allowing citizens to directly elect their president. This constitutional change, when combined with Yudhoyono’s re-election interests had a profoundly positive affect on government spending. As mentioned earlier, government spending for healthcare burgeoned beginning in 2009, in turn having a positive association with reductions in inequality.
In contrast, the case of Russia has revealed the challenges associated with political centralization and a lack of electoral – and thus policy - accountability. In this context, interest in federal spending for healthcare emerged mainly from within the presidential administration. In the absence of presidential concern and interest in international and domestic pressures from civil society, the Putin administration has not had an interest and incentive for ensuring an adequate level of healthcare spending. Until this is achieved, Russia may have a difficult time reducing economic and social inequalities.
In some countries, however, social health movements and pressures on the government for policy reform have been helpful in increasing government spending for public health systems and publically-funded national health insurance programs. Indonesia was by far the best example of this process, exhibiting a heightened increase in civil societal pressures during the 2009 presidential period, building on several years of democratic activism against the Suharto dictatorship. These pressures seem to have helped in motivating the government to increase spending and focus on healthcare, especially among the poor. Social movements and NGOs have also emerged in India through the Jan Swasthya Abhiyan, helping to pressure and hold the government accountable for increased healthcare spending. Civil society’s response in China and Russia and their affects on policy have been weak to non-existent, however, reflecting the dearth of civic activism and pressures on the state as well as the government’s willingness to reach out to and incorporate civil society’s policy recommendations, especially in the area of public health (Gómez and Harris, forthcoming).
Going forward, the international community, media, and civil society can – and indeed should – play a more proactive role in increasing awareness of the association between public health system and publically-funded national health insurance spending and inequality. By working together, these actors may be able to increase greater awareness and compel those politicians concerned with the legitimacy and efficacy of their government to reduce inequality through greater investments in healthcare.
Several policy lessons emerge from this report. Policy-makers and activists in India, China, Russia, and Indonesia should consider these lessons when striving to establish a stronger linkage between increased healthcare spending and reductions in inequality.
• Central governments must continue to increase spending for public health and invest more in the public health system rather than national health insurance programs in order to guarantee access to quality and effective universal healthcare;
• However, governments must combine increased spending with the simultaneous strengthening of institutions, such as healthcare infrastructure, human resources, as well as inter-governmental policy coordination and government regulation of hospital and clinical practices. Strengthening these institutions is vital for ensuring a linkage between healthcare spending and reduced inequality; • At the same time, central and local health officials should work together to locate and educate the
poor and women on their healthcare rights, benefits, and where they can go to receive prevention and treatment services. Governments should complement these efforts with financial assistance to those in need of funding for travel to obtain healthcare. These efforts can help individuals obtain the health and financial benefits associated with increased healthcare access, in turn providing the poor with additional income and the time needed to improve their economic and social positions; • In order to ensure that these outreach roles pay off, however, central governments should invest more
in increasing the regulation of public and private hospital malpractice, such as physicians’ prescriptions of unnecessary medications and tests. Otherwise the poor’s increased registration for voluntary insurance programs may not help them to avoid OOP and catastrophic expenses. Central and local health officials should explore various ways of monitoring, reporting, and disciplining public and private sector doctors for engaging in corrupt activities;
• Given the large size of distant (and at times inaccessible) rural areas in these nations, central governments should create incentives for local health officials to work harder in reaching out to and providing healthcare services to the poor. In addition to providing financial incentives for those healthcare workers in remote areas, state and provincial health departments should receive national – and possibly international – recognition for their efforts to service remote areas, as well as financial benefits by way of increased fiscal transfers for health and other social services. Central government recognition could go a long way in motivating greater outreach efforts and, consequently, increased access to healthcare and reduced inequality;
• Given the effort to ensure universal healthcare in these nations, governments must ensure that increased spending guarantees coverage for all inpatient and outpatient services. Universal healthcare cannot be achieve if the poor continue to experience out-of-pocket and/or catastrophic expenses, which could discourage them from seeking more healthcare services. To avoid this, existing health