Vast 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 US-

based 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 do 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

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 effOrtIn 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

Universal healthcarehigh-growth countries face a challenge to maintain a healthy middle class

S P O N S O R E D B Y :

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 state-

controlled 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 do 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, strOngerIt 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.