Would national health insurance improve equity and efficiency of health care in South Africa? Lessons from Asia and Latin America.

Arguments for and against national health insurance (NHI) for South Africa are illuminated by the experiences of other middle-income developing countries. In many Latin American and Asian countries the majority of their populations are covered by NHI, coverage having steadily increased over the last decade. Patterns of care under NHI tend to be inefficient--hospital-oriented, highly specialised and technical, with excessive investigation, surgery and medication, neglect of primary care and severe cost escalation. In some cases, however, urban primary care has been promoted through polyclinics and health maintenance organisations. Inequalities in funding, access and utilisation exist between the insured and uninsured, between strata of the insured, and between urban and rural areas. These inequalities have at times been ameliorated by expansion of coverage, subsidisation of poorer beneficiaries and initiation of programmes that extend care to rural areas. NHI can improve or impair efficiency and equity in health care, depending on structures and processes of revenue generation, payment and organisation of care. These depend in turn on how those likely to lose or gain from each option exercise their collective power.