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 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 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  ... 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... The ceiling on hospital care costs is set at six times the average annual income—still crippling for many people who not have additional insurance Even so, Jin Xu, a PhD student being funded by