Beyond fragmentation and towards universal coverage: insights from Ghana, South Africa and the United Republic of Tanzania
Beyond fragmentation and towards universal coverage: insights from Ghana, South Africa and the United Republic of Tanzania
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DOI：
10.2471/blt.08.053413
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发表时间：
2008-11-01
期刊：
影响因子：
--
通讯作者：
Goudge, Jane
中科院分区：
文献类型：
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作者：
McIntyre, Diane;Garshong, Bertha;Goudge, Jane
2005年世界卫生大会呼吁所有卫生系统实现全民覆盖，其定义是“让所有人以负担得起的价格获得充足的医疗保健”。实现全民覆盖的一个关键因素是卫生系统中收入和风险交叉补贴的程度。然而，许多针对低收入和中等收入国家的政策处方似乎忽视了这一点，往往导致卫生系统高度分散。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）卫生系统的分散程度。我们使用一个分析医疗保健融资关键功能的框架，描述了碎片化是如何发展的、每个国家如何尝试解决所出现的公平挑战以及促进全民覆盖仍需采取哪些措施。分析表明，南非在解决碎片化问题方面取得的进展最少，而加纳似乎正在以更加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付费用的依赖，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，以平衡个人保险计划之间的风险或公平分配一般税收（和捐助）资金。最终，需要进一步整合融资机制，以在整个卫生系统中通过强有力的收入和风险交叉补贴来促进全民覆盖。
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.