Understanding City and Regional Health Markets in Brazil, Russia, India and China
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BRAZIL - Brazil has made great strides in improving the health of its citizens yet, in common with other emerging markets, distribution of health services is uneven, with wide disparities between regions.
Looking at health expenditureIt is critical for medical and pharmaceutical companies to understand the sometimes confusing funding of healthcare in Brazil. Health expenditure comprises public health expenditure, private health insurance and private out-of-pocket health expenditure. A high proportion of public health expenditure goes towards expensive and complex services, including hospital admissions and diagnostic & therapy services. In recent years, however, public expenditure has shifted towards primary care services.
As public health expenditure has moved towards primary care, the level of access to ambulatory and hospital care has diminished, as public financial resources have not increased at the same level. In 2008, the latest year for which data is available, public health expenditure represented 3.8% of GDP, equal to R$108.9 billion (US$59.3 billion). Alongside the Brazilian health system there is a strong private health insurance sector which, in recent years, has been increasing. Brazil is the second largest insurance market in the world, after the USA.
KEY FACTSThe Brazilian economy experienced real growth of around 2.9% in 2011, to be valued at US$2,485 billion, with average per capita GDP of US$12,889. Brazil is currently the world's 7th largest economy, between France (US$2,773 billion) and the UK (US$2,436 billion). At 194.7 million, the population of Brazil is the fifth largest in the world. Average population growth is around 1.1% per annum. Around 21.6% of the population reside in São Paulo state and 8.4% live in the state of Rio de Janeiro. The 2010 census identified 14.1 million people aged 65 or older, equivalent to 7.4% of the population. In 2011, Brazil spent R$368.2 billion (US$219.8 billion) on healthcare, equivalent to 8.8% of GDP. Private spending accounted for 52.7% of the total, more than half of which was out of pocket spending. Public health spending amounted to US$115.8 billion. Per capita health spending was around US$1,140.RUSSIA - No one would deny that Russia's health system has declined since the fall of the Soviet state and for many years was under-funded and poorly developed. Since 2005, Russian authorities have embarked on ambitious plans to improve matters – progress to date, but will they come up to European standards?
Funding is at the heart of Russia's health improvement plans, and at the beginning of 2011 obligatory medical insurance contributions increased from 3.1% to 5.1%, deductable from salaries. With measures to increase income, has come the challenge of distribution and the recognition that, in common with countries such as India and China, there is a yawning gap between well-provided for cities, and the more remote regions. In 2010, the government introduced the idea of a regional healthcare services modernisation scheme that aims to improve quality and availability of medical service. Healthcare modernisation is well overdue: to put this into context, over 30% of hospitals lack a hot water supply, 8% do not have a drinking water pipeline and 9% lack drainage.
KEY FACTSThe Russian Federation is the largest country in the world, with a land area of over 17 million square kilometres, encompassing eleven time zones. After the breakup of the USSR, the Russian Federation retained over 75% of the USSR's total land area and 51% of its population. The population of Russia was estimated at 142.9 million in 2010, an increase of 0.71% over 2009. Prior to 2010, the growth rate remained negative, decreasing by an average of 0.4% each year since 1999. The country is organised into 8 districts which are further subdivided into 82 regions, autonomous areas and republics.INDIA - India's 1.21 billion population is distributed across 35 states and union territories, and is growing at 1.6% per year. In terms of landmass, India is approximately one third the size of the USA.
India has an established mainly urban middle class but the bulk of the population have little by way of income and resources. This is exacerbated in India where, despite there being over 45 cities with more than 1 million inhabitants, the majority of the population live rurally in over 638,000 villages – many of them remote and difficult to access. The impact on key health indicators, such as infant mortality, can be clearly seen and despite per capita health spending more than doubling in the last 10 years there is some way to go.
Government health spending has not kept pace with private expenditure with health insurance covering no more than 5%. Out of pocket funding of healthcare remains dominant and the growing number of middle classes have been influential in the growth and success of the many private hospital groups.
Compare and Contrast: Haryana and Rajasthan: The Indian market is one of great diversity, and the gap between the 'haves' and 'have nots' is stark. Consider the following comparisons of selected statistics between the two neighbouring north western states of Haryana and Rajasthan which have dramatically different economic drivers.
InformationPopulationGDPGDP per capitaBirth rate per 000Infant mortality per 000 live birthsUrban rateRural rate National1,210,193,000US$1,049 billionUS$101722.1473151 Haryana25,353,000US$42.8 billionUS$172322.3483851 Rajasthan68,621,000US$49.5 billionUS$74826.7555531 CHINA - China: 22 Provinces, four Municipalities and five Autonomous Regions each with an average population of nearly 42 million, each with differing health provision and needs.
China has been a focus of interest for international business for such a long time now that it has become easy to assess markets and economic performance in national terms. Even the much discussed and fast developing urban areas such as Beijing, Shanghai and Tianjin are representative of only a fraction of the widely diverse regional markets to be found elsewhere in the country.
Urban vs. Rural populationUnderstanding the urban/rural divide in China is critical. The number of cities with over one million inhabitants is significant in every province, with migration from rural areas driven by the boom in manufacturing. The economic strength of cities over rural areas has led to an imbalance of health provision; an imbalance the Chinese government is keen to correct through mechanisms such as the New Co-operative Medical System.
A case in point – Anhui Province: The rural challenge
Anhui Province has 61.3 million people - 4.6% of the national population. The capital and largest city is Hefei, with a population of around 3.4 million and other major cities include Huainan (1.9 million), Huangshan (1.5 million) and Ma'anshan (1.4 million). Anhui has below average rates of hospital beds, physicians and nurses, which can be attributed to the province's low GDP per capita rate and large rural population.
Health is delivered via a bewildering array of services including 17,788 village clinics, 1,714 health centres and 710 hospitals, of which 489 were general and 125 were specialist facilities.
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