The role of risk adjustment in the equitable financing of National Health Insurance in South Africa

A National Health Insurance system has been proposed for South Africa and two of the seven guiding principles are that there be social solidarity and equity. These will require both risk cross-subsidies and income cross-subsidies to be engineered into the health care financing system. This paper considers the need for risk adjustment at a provincial level using at least age, gender and HIV prevalence. The proposed single purchaser model with 52 purchasing districts is shown to be problematic. An alternative multiple purchaser model is proposed which includes existing health funds and employer-based health care arrangements. The role of risk adjustment is described at various levels of the system and it is demonstrated that equity and social solidarity can be achieved in a multiple purchaser system.