The political economy of health financing reforms in Zimbabwe: a scoping review

Abstract

Background Implementation of health financing reforms for Universal Health Coverage (UHC) is inherently political. Despite the political determinants of UHC, health financing reform in Zimbabwe is often portrayed as a technical exercise with a familiar path of a thorough diagnosis of technical gaps followed by detailed prescriptions of reform priorities. In this study, we sought to understand the interaction between political and economic aspects of health financing reforms since the country got its independence in 1980. Methods We conducted a scoping review of health financing reforms in Zimbabwe and reviewed 84 relevant sources of information. We then conducted a thematic analysis using an adapted Fox and Reich’s framework of ideas and ideologies, interests and institutions. Results We found that ideas, institutions and interests significantly influence health financing reforms in Zimbabwe with implications on health system performance. Reform priorities of the 1980s were influenced by socialist ideologies with an interest to address pervasive health inequities inherited from the colonial racial system. The progress in equity realized in the 1980s was severely disrupted from the 1990s partly due to neo-liberal ideologies which steered interests towards market-oriented reforms. The period from the 2000s is characterized by increasing donor influence on health financing and a cumulative socio-economic collapse that resulted in a sharp and protracted decline in health spending and widening of health inequities. Conclusion Health financing reform process in Zimbabwe is heavily influenced by political economy characteristics which favor certain financing arrangements over others with profound implications on health system performance. We concluded that the political economy factors that slow down UHC reforms are not rooted in the ambiguities of ideas on what needs to be done. Instead, the missing link is how to move from intention to action by aligning espoused ideas with interests and institutions which is an inherently political and redistributive process. International and domestic actors involved in UHC in Zimbabwe need to explicitly consider the politics of health financing reforms to improve the implementation feasibility of desired reforms.

Beyond political will: unpacking the drivers of (non) health reforms in sub-Saharan Africa

“…The other reform driver relates to the extent to which the private sector perceives the costs and benefits arising from reforms. Private sector interests, particularly market protectionism dampened SHI and NHI oriented reforms in Ghana,43 Uganda,41 Zimbabwe24 and South Africa 39…”

“…We found that political ideologies significantly influenced health reforms, particularly those with widespread redistributive effects. In the 1980s, a socialist political orientation facilitated the adoption of a well-elaborated PHC strategy in Zimbabwe that was influenced by the desire to dismantle the colonial legacy of racially driven health inequities24; a similar path taken by South Africa during the postpartheid era 40. In Ethiopia, the decision to embark on widesperead PHC reforms was rooted in the ruling coalition’s developmental state strategy with a rural bias 31.…”

“…This political settlement paradigm aligns with the positive health transformation experience in Rwanda post the 1994 genocide 23 and Zimbabwe in the 1980s. 133 However, the pursuit of a neoliberal agenda in Zimbabwe in the 1990s; and the attendant adverse effects 24 is emblematic of how a shift towards market oriented political settlements can damage health systems as in the case of Ghana, 134 South Africa 100 and several Latin American countries. 135 This study has highlighted how political elites can dominate reforms and steer policies towards self-interests at the expense of altruistic choices aimed at public benefit.…”

“…[16][17][18][19][20] Political will has been cited as the underlying driver for transformative health sector reforms internationally 15 and among African countries. [21][22][23][24] Political will has been defined as the commitment of actors to undertake actions to achieve a set of objectives and to sustain the costs of those actions over time. 25 Although frequently invoked as a rhetorical tool in political discussions, the concept of political will remains ambiguous and one of the 'slipperiest concept in the policy lexicon'' that is often presented as a 'catch-all culprit' with 'little analytic content'.…”

“…This mismatch is often blamed on the ‘lack of political will’2 15 with persistent demand for it 16–20. Political will has been cited as the underlying driver for transformative health sector reforms internationally15 and among African countries 21–24. Political will has been defined as the commitment of actors to undertake actions to achieve a set of objectives and to sustain the costs of those actions over time 25.…”