Most governments in middle-income countries have not prioritized universal healthcare due to competing needs and a lack of funding. This has led to inequalities between public and private healthcare systems, with public systems often underfunded and providing poor services to the poor. There are also shortages of skilled healthcare workers, particularly in rural areas. While decentralization of healthcare has occurred, governments have not ensured sufficient funding and capacity at state and local levels. Ongoing challenges also include increasing rates of non-communicable diseases like diabetes and issues with malnutrition, air pollution, and healthcare infrastructure between public and private sectors.

1. Barriers to Healthcare in
Middle-Income
Countries
Dr. Eduardo J. Gómez
Department of International Development
King’s College London
Eduardo.gomez@kcl.ac.uk
www.edgomez.org

2. Political and Financial
Commitment
• Most governments have not prioritized access to
universal and quality healthcare
o There are many competing needs, such as economic and national
security policies – e.g., Russia;
o Lack of sufficient federal funding;
o Healthcare issues are not covered by mainstream media – e.g., India.

3. Inequalities in Access to
Healthcare Services
• There are also ongoing inequalities in access to
quality and effective healthcare services
o Public sector providers are often underfunded, providing poor services;
most of the poor use public;
o Private sector has better quality services—used by higher income classes;
o Out-of-pocket and catastrophic expenses affect the poor more than rich,
increasing poverty levels – e.g., China, India, and Brazil

4. Human Resources
• There is also an ongoing shortage of skilled doctors
and nurses, particularly in rural areas
o Primary care workers—mobile teams needed in rural areas
- Brazil’s Family Health Program is a good example
o Skilled nurses are needed, especially for complex diseases, such as type-2
diabetes
o In response to obesity, there is also a need to involve nutritionists and
physical exercise specialists in primary care programs

5. Healthcare Infrastructure
• Governments still need to address inequalities in
access to quality hospitals and primary care clinics
between the public and private sectors
- Specialized equipment and adequate number
of beds in public hospitals;
- Access to reliable and speedy internet,
especially in rural areas – e.g., Peru

6. Decentralization
Processes
• Emerging economies have pursued healthcare
decentralization: both de-concentration and complete
devolution;
• Yet, most governments did not ensure that state and
municipal governments had sufficient funding and technical
capacity to render equitable and effective healthcare
services;
• Going forward, governments need to address resource needs
a the state-level; improve inter-governmental coordination
and cooperation; and ensure civic participation

7. Non-Communicable
Diseases
• Overweight and obesity has become a major problem
• Type-2 diabetes, cancer, and heart disease
• Ongoing challenge of malnutrition (under and over)
among the poor
- e.g., Brazil, India, and Indonesia
• Air pollution and water quality—contributes to respiratory
disease and even type-2 diabetes - e.g., India

8. Effective Receptivity to UK
and other Donor Assistance
• Government commitment to working with the UK and
other bilateral donors needs to improve – e.g. Russia;
• Bureaucratic training and transparency in how funds
are being used, especially at the local level, where
corruption is prevalent;
- which accountability mechanisms are in place?
• Overcoming new political interests and sovereignty
and self-sufficiency - e.g., India, Russia, Indonesia

9. Conclusion
• Several political, health system, and institutional
challenges to effective healthcare in emerging middle-
income countries remain;
• We continuously need to help governments make
healthcare a priority;
• UK and other nations’ assistance needs to target
ongoing health systems challenges—e.g., human
resources, infrastructure, treating complex diseases and
situations – e.g., obesity, diabetes, malnutrition;
• More assistance is also needed in strengthening health
governance, i.e., ensuring civic participation and
accountability in policymaking