In this final module of the course, we will review health systems in two large middle-income countries, Brazil and China. These countries are important for a number of reasons. Firstly, both Brazil and China have systems of healthcare that are moving towards universal coverage. You remember that universal health coverage as defined by the World Health Organization is not an absolute. Achieving universal health coverage is a process and not just a determinate outcome that is reached when a specific proportion of the population achieves access to healthcare. It is rather a problem of whether or not the system is directed at achieving the set of goals that we define by universal health coverage. So what we are concerned about in analyzing these two large middle-income countries is looking at the stresses and strains as the health system in each country moves towards achieving universal health coverage. The second reason for reviewing these two countries, is that Brazil and China adopt quite different pathways for developing systems of universal health coverage. The third reason is that Brazil and China are two very different countries that have very different experiences, different populations and very different levels of wealth. So let's provide a basic overview of these two countries. The population of Brazil is roughly 209 million. As nearly everyone knows, the population of the people's Republic of China is an enormous 1.3 billion. GDP in Brazil is roughly $2 trillion US. The GDP in China is closer to $12 trillion US. GDP per capita in Brazil is $9,912 US per person. The equivalent figure in China is $8,826. So note the difference between the gross amount of GDP and the per capita GDP. Spending in Brazil on health in 1995 amounted to 7% of GDP, by contrast in China, spending amounted to just 4% of GDP. This is significant because at the time, our universal access to healthcare was introduced in Brazil. Brazil started from a higher level of healthcare spending than China. By 2017, health expenditure in Brazil made up roughly %8.9 of GDP, which is not that far below the United Kingdom. The figure in China had grown to %5.6 of GDP. But these figures don't tell the entire story, this graph provides a view of the rates of economic growth in China and Brazil. So what one sees is that China represented by the blue line has a significantly higher rate of growth in GDP over a significant period of time. By contrast we say that in Brazil, there is not only a lower rate of economic growth. But there are particular periods of time in which Brazil has fallen into recession. And for our purposes today is relevant that in 2015 and 2016, Brazil suffered a significant reduction in GDP per capita with really significant consequences for the health system in that country. Finally, Brazil and China both have health systems that are directed towards achieving universal health coverage, but the pathways for the achievement of that goal are different. In Brazil, the movement towards universal health coverage was by way of the expansion of services. It was by way of the implementation of a system to provide primary health services for the poorest segments of the population. Whereas in China, somewhat closer to the experience in Germany, the process of achieving universal health coverage is through an expansion in social health insurance. This throws up quite different issues in both countries that we will review in the following segments of the lecture.