McIntyre Diane, Garshong Bertha, Mtei Gemini, Meheus Filip, Thiede Michael, Akazili James, Ally Mariam, Aikins Moses, Mulligan Jo-Ann, Goudge Jane
Health Economics Unit, University of Cape Town, Observatory, South Africa.
Bull World Health Organ. 2008 Nov;86(11):871-6. doi: 10.2471/blt.08.053413.
The World Health Assembly of 2005 called for all health systems to move towards universal coverage, defined as " access to adequate health care for all at an affordable price" . A crucial aspect in achieving universal coverage is the extent to which there are income and risk cross-subsidies in health systems. Yet this aspect appears to be ignored in many of the policy prescriptions directed at low- and middle-income countries, often resulting in high degrees of health system fragmentation. The aim of this paper is to explore the extent of fragmentation within the health systems of three African countries (Ghana, South Africa and the United Republic of Tanzania). Using a framework for analysing health-care financing in terms of its key functions, we describe how fragmentation has developed, how each country has attempted to address the arising equity challenges and what remains to be done to promote universal coverage. The analysis suggests that South Africa has made the least progress in addressing fragmentation, while Ghana appears to be pursuing a universal coverage policy in a more coherent way. To achieve universal coverage, health systems must reduce their reliance on out-of-pocket payments, maximize the size of risk pools, and resource allocation mechanisms must be put in place to either equalize risks between individual insurance schemes or equitably allocate general tax (and donor) funds. Ultimately, there needs to be greater integration of financing mechanisms to promote universal cover with strong income and risk cross-subsidies in the overall health system.
2005年世界卫生大会呼吁所有卫生系统朝着全民覆盖的方向发展，全民覆盖被定义为“让所有人都能以可承受的价格获得足够的医疗保健”。实现全民覆盖的一个关键方面是卫生系统中收入和风险交叉补贴的程度。然而，在许多针对低收入和中等收入国家的政策处方中，这一方面似乎被忽视了，这往往导致卫生系统高度碎片化。本文的目的是探讨三个非洲国家（加纳、南非和坦桑尼亚联合共和国）卫生系统内的碎片化程度。我们使用一个从关键功能角度分析医疗保健融资的框架，描述了碎片化是如何发展的，每个国家是如何试图应对由此产生的公平挑战的，以及为促进全民覆盖还需要做些什么。分析表明，南非在应对碎片化方面进展最小，而加纳似乎在以更连贯的方式推行全民覆盖政策。为了实现全民覆盖，卫生系统必须减少对自费支付的依赖，最大限度地扩大风险池的规模，并且必须建立资源分配机制，以便在各个保险计划之间平衡风险，或者公平分配一般税收（和捐助者）资金。最终，需要进一步整合融资机制，以促进全民覆盖，并在整个卫生系统中实现强大的收入和风险交叉补贴。
