Inequality and private health insurance in Zimbabwe: history, politics and performance

Abstract

Introduction Zimbabwe has one of the highest rates of private health insurance (PHI) expenditures as a share of total health expenditures in the world. The perfomamce of PHI, known as Medical Aid Societies in Zimbabwe, requires close monitoring since market failures and weaknesses in public policy and regulation can affect overall health system performance. Despite the considerable influence of politics (stakeholder interests) and history (past events) in shaping PHI design and implementation, these factors are frequently sidelined when analyzing PHI in Zimbabwe. This study considers the roles of history and politics in shaping PHI and determining its impact on health system performance in Zimbabwe. Methods We reviewed 50 sources of information using Arksey & O'Malley's (2005) methodological framework. To frame our analysis, we used a conceptual framework that integrates economic theory with political and historical aspects developed by Thomson et al. (2020) to analyze PHI in diverse contexts. Results We present a timeline of the history and politics of PHI in Zimbabwe from the 1930s to present. Zimbabwe's current PHI coverage is segmented along socio-economic lines due to a long history of elitist and exclusionary politics in coverage patterns. While PHI was considered to perform relatively well up to the mid-1990s, the economic crisis of the 2000s eroded trust among insurers, providers, and patients. That culminated in agency problems which severely lessened PHI coverage quality with concurrent deterioration in efficiency and equity-related performance dimensions. Conclusion The present design and performance of PHI in Zimbabwe is primarily a function of history and politics rather than informed choice. Currently, PHI in Zimbabwe does not meet the evaluative criteria of a well-performing health insurance system. Therefore, reform efforts to expand PHI coverage or improve PHI performance must explicitly consider the relevant historical, political and economic aspects for successful reformation.

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“…Zimbabwe has one of the highest rates of private health insurance, suggesting its increasing reliance on access to private hospitals. 8 …”

“…The country has navigated several public health crises, such as the HIV/AIDS and cholera epidemics, in the midst of an economic collapse aggravated by economic collapse and reduced healthcare funding. 8 Most recently, the strain on capacity of public health facilities was seen in the context of the COVID pandemic, where deficiencies in bed space, PPE, and staff engendered issues in Zimbabwe's response efforts, mirroring challenges seen globally in HICs and LMICs alike. 9 While there have been pushes toward establishing effective public health policy through the Ministry of Health, reinvigorating public institutions and adequately supporting public healthcare professionals will require extensive investment from both public and private stakeholders.…”

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“…In 2020, health expenditure as a proportion of GDP was, by country, South Africa 8.58%, The Gambia 2.61% and Zimbabwe 3.43% [ 19 ]; by comparison, the figure was 18.8% and 11.4% in the USA and UK respectively at this time. Access to private healthcare happens in the wealthier minority, with the public health system providing all care to 71% and 70% of the population in Zimbabwe and South Africa, and 96% of the population in The Gambia [ 20 – 22 ]. For South African studies, participants with HIV were retained in the analysis to ensure the populations were representative of the whole study population.…”