Health Economics Unit, University of Cape Town, Health Sciences Faculty, Anzio Road, Observatory, 7925, South Africa.
Health Policy Plan. 2012 Mar;27 Suppl 1:i101-12. doi: 10.1093/heapol/czs003.
South Africa is considering introducing a universal health care system. A key concern for policy-makers and the general public is whether or not this reform is affordable. Modelling the resource and revenue generation requirements of alternative reform options is critical to inform decision-making. This paper considers three reform scenarios: universal coverage funded by increased allocations to health from general tax and additional dedicated taxes; an alternative reform option of extending private health insurance coverage to all formal sector workers and their dependents with the remainder using tax-funded services; and maintaining the status quo. Each scenario was modelled over a 15-year period using a spreadsheet model. Statistical analyses were also undertaken to evaluate the impact of options on the distribution of health care financing burden and benefits from using health services across socio-economic groups. Universal coverage would result in total health care spending levels equivalent to 8.6% of gross domestic product (GDP), which is comparable to current spending levels. It is lower than the status quo option (9.5% of GDP) and far lower than the option of expanding private insurance cover (over 13% of GDP). However, public funding of health services would have to increase substantially. Despite this, universal coverage would result in the most progressive financing system if the additional public funding requirements are generated through a surcharge on taxable income (but not if VAT is increased). The extended private insurance scheme option would be the least progressive and would impose a very high payment burden; total health care payments on average would be 10.7% of household consumption expenditure compared with the universal coverage (6.7%) and status quo (7.5%) options. The least pro-rich distribution of service benefits would be achieved under universal coverage. Universal coverage is affordable and would promote health system equity, but needs careful design to ensure its long-term sustainability.
南非正在考虑引入全民医疗保健系统。政策制定者和公众的一个主要关注点是这项改革是否负担得起。模拟替代改革方案的资源和收入生成要求对于决策至关重要。本文考虑了三种改革情景：通过增加一般税收和额外专用税向卫生部门拨款来为全民医疗保险提供资金；将私人医疗保险扩大到所有正规部门工人及其家属，并为其余人员提供税收资助的服务，作为另一种改革选择；以及维持现状。每个方案都在 15 年期间使用电子表格模型进行建模。还进行了统计分析，以评估各种选择对卫生保健融资负担的分布以及不同社会经济群体使用卫生服务的利益的影响。全民医疗保险将导致医疗保健总支出水平相当于国内生产总值（GDP）的 8.6%，与当前支出水平相当。这低于现状方案（占 GDP 的 9.5%），远低于扩大私人保险覆盖范围的方案（超过 GDP 的 13%）。但是，公共卫生服务资金必须大幅增加。尽管如此，如果通过对应纳税所得额征收附加费（而不是增加增值税）来筹集额外的公共资金，那么全民医疗保险将产生最具渐进性的融资系统。扩展私人保险计划方案将是最缺乏渐进性的方案，并且将带来非常高的支付负担；与全民医疗保险（6.7%）和现状（7.5%）方案相比，平均医疗保健总支出将占家庭消费支出的 10.7%。在全民医疗保险下，服务利益的分配最不利于富人。全民医疗保险是负担得起的，并将促进卫生系统公平，但需要精心设计以确保其长期可持续性。
