Health Economics Unit, Department of Public Health and Family Medicine, Health Sciences Faculty, University of Cape Town, Anzio Road, Observatory, 7925, South Africa.
Health Policy Plan. 2012 Mar;27 Suppl 1:i35-45. doi: 10.1093/heapol/czs005.
There is a global challenge for health systems to ensure equity in both the delivery and financing of health care. However, many African countries still do not have equitable health systems. Traditionally, equity in the delivery and the financing of health care are assessed separately, in what may be termed 'partial' analyses. The current debate on countries moving toward universal health systems, however, requires a holistic understanding of equity in both the delivery and the financing of health care. The number of studies combining these aspects to date is limited, especially in Africa. An assessment of overall health system equity involves assessing health care financing in relation to the principles of contributing to financing according to ability to pay and benefiting from health services according to need for care. Currently South Africa is considering major health systems restructuring toward a universal system. This paper examines together, for both the public and the private sectors, equity in the delivery and financing of health care in South Africa. Using nationally representative datasets and standard methodologies for assessing progressivity in health care financing and benefit incidence, this paper reports an overall progressive financing system but a pro-rich distribution of health care benefits. The progressive financing system is driven mainly by progressive private medical schemes that cover a small portion of the population, mainly the rich. The distribution of health care benefits is not only pro-rich, but also not in line with the need for health care; richer groups receive a far greater share of service benefits within both public and private sectors despite having a relatively lower share of the ill-health burden. The importance of the findings for the design of a universal health system is discussed.
卫生系统在提供和筹资两方面确保公平性方面面临着全球性挑战。然而，许多非洲国家仍然没有公平的卫生系统。传统上，卫生保健提供和筹资的公平性是分开评估的，可以称之为“局部”分析。然而，目前关于各国向全民健康系统迈进的辩论需要对卫生保健提供和筹资两方面的公平性有一个整体的理解。迄今为止，将这些方面结合起来的研究数量有限，尤其是在非洲。全面评估卫生系统公平性涉及根据支付能力为卫生保健筹资以及根据卫生服务需求获益来评估卫生保健筹资。目前，南非正在考虑对卫生系统进行重大结构调整，向全民系统迈进。本文共同审查了南非公共和私营部门卫生保健提供和筹资的公平性。本文使用具有全国代表性的数据集和评估卫生保健筹资累进性和受益发生率的标准方法，报告称南非的筹资系统总体上是累进的，但卫生保健效益的分配却有利于富人。累进筹资系统主要是由覆盖一小部分人口（主要是富人）的累进私人医疗计划驱动的。卫生保健效益的分配不仅有利于富人，而且也不符合卫生保健需求；在公共和私营部门中，较富裕群体尽管承担的疾病负担相对较低，但获得的服务效益份额却大得多。讨论了这些发现对全民健康系统设计的重要性。
