title: Beyond fragmentation and towards universal coverage: insights from Ghana, South Africa and the United Republic of Tanzania.
abstract: 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.
authors.affiliation: Health Economics Unit, University of Cape Town, Observatory, South Africa. Diane.McIntyre@uct.ac.za
authors.forename: Diane
authors.initials: D
authors.lastname: McIntyre
authors.forename: Bertha
authors.initials: B
authors.lastname: Garshong
authors.forename: Gemini
authors.initials: G
authors.lastname: Mtei
authors.forename: Filip
authors.initials: F
authors.lastname: Meheus
authors.forename: Michael
authors.initials: M
authors.lastname: Thiede
authors.forename: James
authors.initials: J
authors.lastname: Akazili
authors.forename: Mariam
authors.initials: M
authors.lastname: Ally
authors.forename: Moses
authors.initials: M
authors.lastname: Aikins
authors.forename: Jo-Ann
authors.initials: JA
authors.lastname: Mulligan
authors.forename: Jane
authors.initials: J
authors.lastname: Goudge
mesh_terms: D003431:Cross-Cultural Comparison; D003906:Developing Countries / Q000191:economics*; D005869:Ghana; D018166:Health Care Reform; D006297:Health Services Accessibility / Q000191:economics*; D006801:Humans; D015271:Insurance Pools; D009313:National Health Programs; D011057:Politics; D011203:Poverty; D040841:Resource Allocation; D020414:Risk Sharing, Financial; D012935:Social Justice; D013019:South Africa; D013636:Tanzania; D019472:Universal Health Insurance / Q000191:economics*