Department of Statistics and Actuarial Science, University of Stellenbosch, Box 217, Barrydale, Western Cape 6750, South Africa.
Health Policy. 2010 Nov;98(1):27-38. doi: 10.1016/j.healthpol.2010.06.008.
South Africa intends implementing major reforms in the financing of healthcare. Free market reforms in private health insurance in the late 1980s have been reversed by the new democratic government since 1994 with the re-introduction of open enrolment, community rating and minimum benefits. A system of national health insurance with income cross-subsidies, risk-adjusted payments and mandatory membership has been envisaged in policy papers since 1994. Subsequent work has seen the design of a Risk Equalisation Fund intended to operate between competing private health insurance funds. The paper outlines the South African health system and describes the risk equalisation formula that has been developed. The risk factors are age, gender, maternity events, numbers with certain chronic diseases and numbers with multiple chronic diseases. The Risk Equalisation Fund has been operating in shadow mode since 2005 with data being collected but no money changing hands. The South African experience of risk equalisation is of wider interest as it demonstrates an attempt to introduce more solidarity into a small but highly competitive private insurance market. The measures taken to combat over-reporting of chronic disease should be useful for countries or funders considering adding chronic disease to their risk equalisation formulae.
南非拟对医疗保健融资进行重大改革。1980 年代末，私营医疗保险领域的自由市场改革在 1994 年新的民主政府上台后被推翻，重新引入了开放式注册、社区评级和最低福利。自 1994 年以来，政策文件中一直设想建立一种具有收入交叉补贴、风险调整支付和强制性成员资格的国家健康保险制度。随后的工作设计了一个旨在在竞争激烈的私人健康保险基金之间运作的风险均衡基金。本文概述了南非的卫生系统，并描述了已经开发的风险均衡公式。风险因素包括年龄、性别、孕产事件、某些慢性病患者人数和多种慢性病患者人数。自 2005 年以来，风险均衡基金一直在影子模式下运行，收集数据但不进行资金转移。南非的风险均衡经验具有更广泛的意义，因为它表明了在一个规模虽小但竞争激烈的私人保险市场中引入更多团结的尝试。南非为打击慢性病过度报告而采取的措施对于那些正在考虑将慢性病纳入其风险均衡公式的国家或资助者来说应该是有用的。
