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Respondents were asked to self-assess their area of expertise. Nineteen respondents reported having expertise on at least two of the BRICS countries and 14 on more than two countries. Overall, 19 respondents considered themselves experts on China, India, and South Africa, 18 on Brazil and 10 on Russia. Area of expertise was used as an interpretative criterion during the analysis phase Table 1. Interviews were conducted utilizing a semi-structured questionnaire that included both closed- and open-ended questions.

These streams develop independently and rely on three processes: problem recognition, formulation of policy proposals and politics. The questionnaire included three sections. The closed questions were analysed with simple descriptive statistics using STATA 12 and the open-ended questions were analysed using a grounded theory approach Glaser ; Bryman and Burgess The text of open-ended questions was coded manually by the interviewers. The main ideas expressed in every interview were highlighted, looking for similarities and differences in the responses and grouped into similar concepts and categories.

To preserve anonymity, this study does not attribute direct quotes to interviewees, but only the country of expertise, whether the responder work at national or global level, and in which sector Table 1. The reasons behind the global support for UHC have not been studied yet. According to the interviewees, various ideas and practical necessities have been crucial co-determinants for the global embracement of UHC. From a theoretical point of view, UHC epitomizes a successful synthesis of multiple previous efforts to improve population health by strengthening health systems, enabling universal access to services and protecting citizens from financial hardship.

All these ideas, embodied over 35 years ago in the spirit of the Alma Ata Declaration, fostered a growing consensus around UHC ideology. From a practical point of view, UHC recognition globally occurred only when it was identified as a priority in both high- and low-income countries.

High-income countries have been facing tough challenges to maintain the level and the quality of services provided, while ongoing economic development in low- and middle-income countries dictated a need for reorganizing the traditional donor—recipient north—south relationships. Plus, developed countries have contributed to the debate given the crisis they are facing in their health systems. For instance, the relevance attributed by respondents to the three dimensions of UHC adopted by the WHR —population covered, services covered and proportion of costs covered financial protection varied across the five countries Figure 1.

Although other elements, like the importance of a legal framework underpinning the policy, seemed to be relevant for Brazil, Russia, South Africa and India. The reasons for such variability might be partly attributable to the fact that some or many elements in the concept of UHC, though not necessarily with the current acronym, have been used in national debates long before the international recognition of the terminology. This aspect emerged in particular for the case of Brazil.

For example, one respondent noted that, In Brazil we do not see any innovation from the principles that were already present. Affordability, not having to pay for care…. Another interviewee supported this point for Brazil and, to some extent, for India and China, Brazil committed to UHC far before this issue became important at the international level. Their conceptualization stressed the importance of the judicial side, but they did a pretty good job in putting in place the necessary infrastructure to deliver on that entitlement the constitution provided, unlike what happened in other countries.

Brazil has therefore been less influenced recently because they did it long before. India has been pretty influenced recently by global thinking of UHC although it occupied a leading role with the RSBY program, providing people below the poverty line with insurance coverage [. So these countries were talking about universal coverage before it became an international fad.

This hypothesis seemed to be supported by the fact that almost one-third of the interviewees had heard about UHC before , the year in which a World Health Assembly resolution The BRICS largely constitute a political forum, a coalition of countries to strengthen their influence on priority concerns in the international system, coordinate common interests and identify areas for cooperation. Brazil endorsed all eight official commitments, South Africa supported all but the ministerial conference on Health Systems Financing of , India supported six, China five, and Russia endorsed only four.

Resolution on Sustainable health financing, universal coverage and social health insurance. Resolution on Primary health care, including health systems strengthening which included UHC of maternal, newborn and child health. Top officials from health and finance ministries from 27 countries joined high-level health professionals for discussing ways that countries are progressing towards UHC. Welcome the growing global support for UHC and sustainable development.

They emphasized the importance of monitoring progress towards UHC. Point Recognition of the need to combat unequal access to health systems and pledges to support social protection floors as defined by countries to address specific needs.

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Participants agreed to promote the inclusion of UHC as an important element in the international development agenda. Participants agreed to: raise awareness on health financing, coordinate their efforts towards achieving UHC, encourage political commitment towards UHC in all African countries, etc.

Stated that all States involved in the conference should work towards UHC and more specifically towards access to services. Overview of UHC in Africa: expectations, progress and challenges; discussions on how to increase the financing for UHC in African countries and how to improve its management; conclusion on the role of national leaders and global partners in the promotion of UHC.

The nations involved agreed to strengthen primary care and improve efficiency in service delivery and equity in financial protection. Most respondents attributed the reason for this influence to the economic strength of the countries and to their position in the international and geopolitical arenas.


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One respondent argued that, India and China are definitely heard for economic and size reasons […]. I mean, these countries are all regional hegemons. Everyone listens to Brazil. They are very strong and highly regarded. India […] is quite influential regionally, especially in WHO terms and it has got some big international thinkers.

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For example, one respondent argued that, They all exert political influence. In UHC they are politically influential in getting resolutions adopted. This is what they have done until now. The majority of key informants indicated that BRICS do not engage in joint activities to support UHC and that, in the global health arena, they do not work as a group. Moreover, among those that answered positively to the existence of partnerships between BRICS countries for UHC, very few were able to mention precise examples.

Their engagement is, however, different. Regional leadership may be linked to domestic achievements. The leadership of Brazil in the region was critical in the construction of the South American Health Council in , which started a process of integration in the domain of health that became a strategic policy driver redefining the terms of regionalism in South America Riggirozzi Brazilian leadership was also instrumental to the international presence and joint action of UNASUR countries in international health governance contexts i.

According to some respondents, also China and India displayed a regional sphere of influence mainly by disseminating their experience to neighbouring countries, although only the example of the Indian insurance scheme Rashtriya Swasthya Bima Yojna RSBY , promoted in Bangladesh, Nepal and Vietnam Reddy was actually documented.

Most respondents believe that the recent health system changes have been influenced by a UHC goal in all BRICS countries except Russia, although the consensus among respondents was slightly weaker Figure 4. Since that time, health policies have been demanding rights-based universal health services and there has continually been strong support from a powerful epistemic community of activists, academics, politicians and bureaucrats Shankland and Cornwall ; Russo and Shankland When asked whether UHC was considered an important goal of the Brazilian domestic agenda most interviewees claimed that the concept was of little use for dealing with the problems faced by the Brazilian health system, because its principles had been already embraced during the s reform.

In , the Chinese government announced a national Reform Plan which would lead to achieving nearly universal coverage by Qingyue and Shenglan In addition, multiple States in India launched State Government initiatives, mainly aimed at preventing individuals from facing catastrophic healthcare expenditures. Although the move towards UHC is currently on the political agenda, the South African health system is still considered to be inequitable with a pro-rich distribution of health services, not only due to heavy reliance on the private sector but also because of inequity in access to public sector services Ataguba and McIntyre Yet most responders mentioned that, at least in the case of China, India and South Africa, it appears to be driven by national needs.

This is translated in the way that reforms are ascribed to a long-term aim to walk towards UHC and are shaped by the individual context of these countries. On the India side, it is actually the agility of the system and its infrastructure that matters. This is an interesting, though questionable, view which it was not possible to further investigate in this study. The influence that BRICS and other emerging countries may exert on the global UHC debate, whether as a coordinated group or as individual countries, may offer insights on their overall role in determining the global health agenda.

Although many responders do not believe the BRICS have been influential in the construction of the UHC concept, this political support indicates these countries may have played an important role in the surge of the global UHC movement. However, BRICS countries do not share the same level of political involvement, with Brazil, China and South Africa constantly on the front lines and the others, notably Russia, lagging behind. Most responders believed China, India, South Africa and to some extent Brazil, are implicitly supporting the global movement for UHC largely in response to internal needs.

Interviewed informants agreed that, in the global health arena, BRICS countries act more as individual countries rather than as an allied group, possibly limiting collaboration internal to the group to the engagement in bilateral agreements. BRICS countries thus, more individually than as a block, seem to be influential in supporting the UHC movement having a claim to a hearing in global health arenas and promoting UHC in their region.

Although their internal health challenges seem to drive them to give more emphasis to specific issues, the UHC conceptualization is largely accepted in BRICS countries. The fact that the recent reforms in some of these countries—namely China, India and South Africa—were inspired by the UHC concept further indicates their engagement in the UHC movement individually if not as a block.

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Although this study provides some interesting suggestions, understanding how BRICS countries exert influence and their potential interest in playing a more active role remains unclear. This may imply that they, either individually or as a group, might become increasingly influential players shaping the global health agenda.

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We would like to thank the participants of the meeting convened in May by the Global Health and Development group at Bocconi University and hosted by the Rockefeller Centre in Bellagio, Italy, for the insightful discussions and for their availability to share their knowledge. We would also like to thank Dondald de Savigny for the helpful comments provided on this manuscript, Lara Gautier for her support in reviewing the global commitments for UHC and for her inputs in preparation of the study, and Andrew Harmer for his initial contribution to define a theoretical framework. All responsibilities for the manuscript rest with the authors.

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