The challenges of pursuing private health insurance in low- and middle-income countries: lessons from South Africa

McIntyre, Di; McLeod, Heather

doi:10.1017/9781139026468.012

Cited by 7 publications

(19 citation statements)

References 225 publications

(8 reference statements)

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“…While enrollment on PHI in the colonial era was based on institutionalized racism, wealth, and employment status became the basis of enrollment in independent Zimbabwe. These historical shifts mirror South African patterns during and post-apartheid [ 59 ]. Currently, PHI coverage in Zimbabwe is influenced by the wealth index, as with South Africa, Nigeria, Togo, Benin and Mali, and Madagascar [ 60 , 61 ].…”

Section: Discussionmentioning

confidence: 94%

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

Mhazo

Maponga

Mossialos

2023

Int J Equity Health

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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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Section: Discussionmentioning

confidence: 94%

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

Mhazo

Maponga

Mossialos

2023

Int J Equity Health

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“…The effects of this decision are complex. On the one hand, the resultant policy changes led to private-sector growth (including increased numbers of black South Africans using private providers and medical schemes), with the consequence that post-1994 HSR efforts faced resistance from a strong and established private sector [73]. On the other hand, concern that the state was abdicating its responsibility as a provider of health services and regulator of the private sector reignited interest in HSR among academics and civil society actors, and de-regulation facilitated a cost-explosion that would make the need for HSR all the more evident [33].…”

Section: Discussionmentioning

confidence: 99%

“…In the health sector, the government's response to budgetary pressures reveals an acceptance of, and commitment to, neoliberal economic ideologies that legitimate the state's abdication of the responsibility for the provision of healthcare, the privatisation of service delivery and a focus on individual responsibility [67, 70,72]. In 1986, the Browne Commission Inquiry into Health Services, clearly in uenced by a commitment to privatisation, conceded that there was no evidence that the private sector is more e cient, and that privatisation had no bene t to users, but nonetheless supported deregulation of medical schemes, including the acceptance of risk rating, threshold payments, and co-payments and deductibles [70,73,74]. In "an ironic reversal of the Gluckman commission" the Browne Commission also said that the development of primary health centres should be determined only after accounting for the likely expansion of the private sector [53].…”

Section: Introductionmentioning

confidence: 99%

“…The result of these policy decisions was a dramatic expansion of the private health sector, particularly for-pro t hospitals, [13] driven largely by increasing medical scheme membership among black people [67,73]. However, as the private health sector grew, the challenges associated with private provision of healthcare became increasingly clear.…”

Section: Introductionmentioning

confidence: 99%

“…Public sector fees for paying patients were rapidly increased, to the point that it was more expensive for 'middle-class' patients to obtain out-patient services in the public sector, than to visit a private provider [67,75]. And medical scheme membership was opened to people of all races (having been restricted to white people) [17,73]. The Medical Schemes Amendment Act -pushed through in the dying days of apartheid -abolished guaranteed payments to providers, removed mandatory minimum bene ts, re-enabled risk rating, and excluded many of the most vulnerable from medical scheme coverage [33,68].…”

Section: Introductionmentioning

confidence: 99%

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A socio-political history of the South African National Health Insurance

Whyle

Olivier

2023

Preprint

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Background Health policy processes are invariably shaped by social, political and historical realities. Spurred by the WHO’s endorsement of universal health coverage as a universal health system goal, many countries are undertaking health financing reforms. The nature of these reforms and the process by which they are achieved will depend on context-specific factors, including the history of reform efforts and the political imperatives driving contemporary reforms. South Africa’s pursuit of universal health coverage through a National Health Insurance is the latest in a nearly 100-year history of health system reform efforts shaped by social and political realities. Methods We conducted an interdisciplinary, retrospective literature review to develop an account of how health system reform efforts have unfolded, shaped by the contextual realities of the moment. We began the review by identifying peer-reviewed literature on health system reform in South Africa and iteratively expanded the search through author tracking, citation tracking and purposeful searches for material on particular events or processes referenced in the initial body of evidence. Data was extracted and organised chronologically into nine periods. Results The analysis suggests that in South Africa politics; the power of the private sector; competing policy priorities and budgetary constraints; and ideas, values and ideologies have been particularly important in constraining, and sometimes spurring, health system reform efforts. Political transitions and pressures, including the introduction of apartheid in 1948, anti-apartheid opposition, the transition to democracy, and corruption and governance failures, have alternately created political imperatives for reform, and constrained reform efforts. In addition, the country’s political history has given rise to dominant ideas, values and ideologies that imbue health system reform with a particular social meaning. While these ideas and values increase opposition and complicate reform efforts, they also help to expose the inequities of the current system as problematic and re-emphasise the need for reform. Conclusions Ultimately, this analysis demonstrates the context-specific nature of health system reform processes and the influence of history on what sorts of reforms are politically feasible and socially acceptable. In addition, the analysis reveals the value of a historical perspective to understanding the challenges facing contemporary reforms.

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Financial Health of Medical Schemes in South Africa

Alhassan

2023

Finance Research Letters

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The challenges of pursuing private health insurance in low- and middle-income countries: lessons from South Africa

Cited by 7 publications

References 225 publications

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

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

A socio-political history of the South African National Health Insurance

Financial Health of Medical Schemes in South Africa

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