The potential role of risk-equalization mechanisms in health insurance: the case of South Africa.
International agencies such as the World Bank have widely advocated the use of health insurance as a way of improving health sector efficiency and equity in developing countries. However, in developing countries with well-established, multiple-player health insurance markets, such as South Africa, extension of insurance coverage is now inhibited by problems of moral hazard, and associated cost escalation and fragmentation of insurer risk-pools. Virtually no research has been done on the problem of risk selection in health insurance outside developed countries. This paper provides a brief overview of the problem of risk fragmentation as it has been studied in developed countries, and attempts to apply this to middle-income country settings, particularly that of South Africa. A number of possible remedial measures are discussed, with risk-equalization funds being given the most attention. An overview is given of the risk-equalization approach, common misconceptions regarding its working and the processes that might be required to assess its suitability in different national settings. Where there is widespread public support for social risk pooling in health care, and government is willing and able to assume a regulatory role to achieve this, risk-equalization approaches may achieve significant efficiency and equity gains without destroying the positive features of private health care financing, such as revenue generation, competition and free choice of insurer.