Social solidarity and willingness to tolerate risk- and income-related cross-subsidies within health insurance: experiences from Ghana, Tanzania and South Africa

Jane Goudge, James Akazili, John Ataguba, August Kuwawenaruwa, Josephine Borghi, Bronwyn Harris, Anne Mills

The importance of ill-health in perpetuating poverty is well recognized. In order to prevent the damaging downward spiral of poverty and illness, there is a need for a greater level of social protection, with greater cross-subsidization between the poor and wealthy, and the healthy and those with ill-health.

The aim of this paper is to examine individual preferences for willingness to pre-pay for health care and willingness to cross-subsidize the sick and the poor in Ghana, South Africa and Tanzania. Household surveys in the three countries elicited views on cross-subsidization within health care financing. The paper examines how these preferences varied by socio-economic status, other respondent characteristics, and the extent and type of experience of health insurance in the light of country context.

In South Africa and Ghana, 62% and 55% of total respondents, respectively, were in favour of a progressive financing system in which richer groups would pay a higher proportion of income than poorer groups, rather than a system where individuals pay the same proportion of income irrespective of their wealth (proportional). In Tanzania, 45% of the total sample were willing to pay for the health care of the poor. However, in all three countries, a progressive system was favoured by a smaller proportion of the most well off than of less well off groups.

Solidarity has been considered to be a collective property of a specific socio-political culture, based on shared expectations and developed as part of a communal, historical learning process. The three countries had different experiences of health insurance and this may have contributed to the above differences in expressed willingness to pay between countries. Building and ‘living with’ institutions that provide affordable universal coverage is likely to be an essential part of the learning process which supports the development of social solidarity.

Financing Tanzania South Africa