Читать книгу The Political Economy of the BRICS Countries - Группа авторов - Страница 80

There are two important angles to the UHC process that are often overlooked, one more than the other. These are reforms and governance. While reforms are often talked about, there are few studies that have looked at the comparative picture of reforms in the health sector in countries to see why countries have such uneven records in terms of progress towards universal access. We deliberately mention health sector reforms rather than reforms for UHC, because to achieve good outcomes in the health sector requires much more than merely putting in place UHC systems. In fact, for UHC to work, one needs a series of incremental reforms — big or small — happening steadily over time.

Mere allocation of public resources does not always yield the desired outcomes. This is primarily due to the quality of governance, a concept that is elusive and, therefore its measurement, very often subjective. An indistinct relationship between public spending and outcome is often related to the aspect of governance (Pritchett, 1996). There have been a number of studies linking overall governance performance with health outcomes. Some studies (Kaufmann et al., 1999, 2004; Gupta et al., 1999) have found governance indicators like voice and accountability, political stability and violence, government effectiveness, regulatory burden, rule of law, and graft to be significantly negatively related to infant mortality. Also, investment patterns have been seen to change with significant corruption, with investments being disproportionately more on physical infrastructure rather than health and education (De la Croix and Delavallade, 2006). Other studies show that greater citizen participation and better governance can lead to greater efficacy in government action in general (Isham et al., 1997). Also, political commitment, higher tax revenues, and greater democracy are associated with a higher share of GDP going to public health spending (Stuckler 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−X_min)/(X_max−X_min), 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.