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International Journal for Equity in Health
Published in: International Journal for Equity in Health 1/2023

Open Access 01-12-2023 | Research

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

Authors: Alison T. Mhazo, Charles C. Maponga, Elias Mossialos

Published in: International Journal for Equity in Health | Issue 1/2023

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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.
Literature
1.
Cutler D, Zeckhauser R. The anatomy of health insurance, in Handbook of Health Economics, A.J. Culyer and J.P. Newhouse, Editors. 2000, Elsevier. p. 563–643.
2.
Sekhri N, Savedoff W. Regulating private health insurance to serve the public interest: policy issues for developing countries. Int J Health Plann Manage. 2006;21(4):357–92.PubMedCrossRef
3.
Kutzin J. A descriptive framework for country-level analysis of health care financing arrangements. Health Policy. 2001;56(3):171–204.PubMedCrossRef
4.
Foubister T, et al. Private medical insurance in the United Kingdom. Copenhagen: European observatory on health systems and policies; 2006.
5.
Mossialos E, Thomson S. Voluntary health insurance in the European Union. Brussels: WHO European Observatory on Health Systems and Policies; 2004.
6.
Sekhri N, Savedoff W. Private health insurance: implications for developing countries. Bull World Health Organ. 2005;83(2):127–34.PubMedPubMedCentral
7.
Thomson S, Sagan A, Mossialos E. Why private health insurance? In: Sagan A, Mossialos E, Thomson S, editors. Private Health Insurance: History, Politics and Performance. Cambridge: Cambridge University Press; 2020. p. 1–40.CrossRef
8.
Eisenhauer JG. “The theory of demand for health insurance”: a review essay. Journal of Insurance Issues. 2006;29(1):71–87.
9.
Arrow KJ. Uncertainty and the welfare economics of medical care. Am Econ Rev. 1963;53(5):941–73.
10.
Major I. Two-sided information asymmetry in the healthcare industry. Int Adv Econ Res. 2019;25(2):177–93.CrossRef
11.
Bloom G, Standing H, Lloyd R. Markets, information asymmetry and health care: towards new social contracts. Soc Sci Med. 2008;66(10):2076–87.PubMedCrossRef
12.
Besley T. The demand for health care and health insurance. Oxf Rev Econ Policy. 1989;5(1):21–33.CrossRef
13.
Cerovic, L., N. Dukić Samaržija, and T. Horvat, The agency problem in healthcare and the importance of incentives. 2012.
14.
Shavell S. Risk sharing and incentives in the principal and agent relationship. The Bell Journal of Economics. 1979;10(1):55–73.CrossRef
15.
Eulau H, Zlomke S, Harold D. Lasswell’s legacy to mainstream political science: a neglected agenda. Ann Rev Pol Sci. 1999;2(1):75.
16.
Smith PC, et al. Principal-agent problems in health care systems: an international perspective. Health policy (Amsterdam, Netherlands). 1997;41(1):37–60.PubMedCrossRef
17.
Mwachofi A, Al-Assaf AF. Health care market deviations from the ideal market. Sultan Qaboos Univ Med J. 2011;11(3):328–37.PubMedPubMedCentral
18.
Iszaid I, Hafizan A.H, Juni M. Market failure in health care: a review. Int J Public Health Clin Sci. 2018;5(5):16–25.CrossRef
19.
Pauly MV. The economics of moral hazard: comment. Am Econ Rev. 1968;58(3):531–7.
20.
Seyedin H, et al. The main factors of supplier-induced demand in health care: a qualitative study. Journal of education and health promotion. 2021;10:49.PubMedPubMedCentralCrossRef
21.
Rice TH. The impact of changing medicare reimbursement rates on physician-induced demand. Med Care. 1983;21(8):803–15.PubMedCrossRef
22.
Crane TS. The problem of physician self-referral under the medicare and Medicaid antikickback statute. JAMA. 1992;268(1):85.PubMedCrossRef
23.
Rizzo JA, Blumenthal JA. Is the target income hypothesis an economic heresy? Medical care research and review : MCRR. 1996;53(3):243–66.
24.
Nguyen NX, Derrick FW. Physician behavioral response to a Medicare price reduction. Health Serv Res. 1997;32(3):283–98.PubMedPubMedCentral
25.
Zimbabwe ministry of health and child care. Zimbabwe national health accounts. Harare; 2015.
26.
Mhazo AT, Maponga CC. The political economy of health financing reforms in Zimbabwe: a scoping review. Int J Equity Health. 2022;21(1):1–14.
27.
Mossialos E, Thomson SMS. Voluntary health insurance in the european union: a critical assessment. Int J Health Serv. 2002;32(1):19–88.PubMedCrossRef
28.
Ncube G. ‘The problem of the health of the native’: colonial rule and the rural African healthcare question in Zimbabwe, 1890s–1930. South African Historical Journal. 2012;64(4):807–26.CrossRef
29.
Steele, M.C., The foundations of a" native" policy: Southern Rhodesia, 1923–1933. 1972.
30.
31.
Valentine, C., Settler visions of health: Health care provision in the central African Federation, 1953–1963. 2017.
32.
Ncube, G., The making of rural health care in colonial Zimbabwe: a history of the Ndanga Medical Unit, Fort Victoria, 1930–1960s. 2012.
33.
Webster MH. The medical services of Rhodesia. Canadian Journal of Public Health / Revue Canadienne de Sante’e Publique. 1966;57(3):117–22.
34.
35.
Woelk GB. Primary health care in Zimbabwe: can it survive? an exploration of the political and historical developments affecting the implementation of PHC. Soc Sci Med 1982. 1994;39(8):1027–35.
36.
Nyazema NZ. The Zimbabwe crisis and the provision of social services. Journal of Developing Societies (Sage Publications Inc). 2010;26(2):233–61.CrossRef
37.
Zimbabwe Ministry of Health and Child care. Zimbabwe National Health Financing Strategy. 2017. Harare, Zimbabwe.
38.
Zimbabwe ministry of health and child care. Zimbabwe national health accounts. Harare, Zimbabwe: 2018. 
39.
Zimbabwe ministry of health and child care. Zimbabwe national health accounts. Harare, Zimbabwe: 2010.
40.
41.
Manga P. The transformation of Zimbabwe’s health care system: a review of the white paper on health. Soc Sci Med 1982. 1988;27(11):1131–8.
42.
The world Bank. Financing Health Services in Developing Countries. 1987.
43.
Shamu S, Loewenson R, Machemedze R, Mabika A. Capital flows through medical aid societies in Zimbabwe’s health sector. The regional network for equity in health in East and Southern Africa (EQUINET) discussion paper series, 82. 2010.
44.
Campbell P, et al. Applying managed care concepts and tools to middle-and lower-income countries: the case of medical aid societies in Zimbabwe. data for decision making project, Harvard school of public health, publication. 2000;(84).
45.
Hongoro C, Kumaranayake L. Do they work? Regulating for-profit providers in Zimbabwe. Health Policy Plan. 2000;15(4):368–77.PubMedCrossRef
46.
Sagan, A. and S. Thomson, voluntary health insurance in Europe: role and regulation: health policy series. 2016.
47.
Arksey H, O’Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8(1):19–32.
48.
Philip N. Medical aid services in southern rhodesia. S Afr Med J. 1957;31(34):858–9.
49.
Manga P. The transformation of Zimbabwe’s health care system: a review of the white paper on health. Soc Sci Med. 1988;27(11):1131–8.
50.
Normand, C., et al., Resource mobilization for the health sector in Zimbabwe, in data for decision making project. 1996.
51.
Segall M. Planning and politics of resource allocation for primary health care: promotion of meaningful national policy. Soc Sci Med. 1983;17(24):1947–60.PubMedCrossRef
52.
Mudyarabikwa, O., Public sector subsidies to the privatehealth sector in Zimbabwe. 2000, EQUINET: Harare, Zimbabwe.
53.
Gandidzanwa A. An exploration of factors that influence health insurance participation by urban high-density households in Zimbabwe: Case of Budiriro 1. Doctoral Dissertation, University of Zimbabwe; 2018.
54.
Sanders D, Davies R. The economy, the health sector and child health in Zimbabwe since independence. Soc Sci Med. 1988;27(7):723–31.PubMedCrossRef
55.
Mufudza T, Naidoo V. Customer perceptions and expectations of medical insurance service quality rendered by companies in Zimbabwe. Journal of Contemporary Management. 2018;15(1):48–77.
56.
The quarterly journal of the Rhodesian economic society, in labour problems in Rhodesia, A.M. Hawkins, Editor. 1972: Salisbury, Rhodesia.
57.
58.
McIntyre, D. Private sector involvement in funding and providing health services in South Africa: implications for equity and access to health care. EQUINET. Harare: health economics unit: 2010.
59.
McIntyre D, McLeod H. The challenges of pursuing private health insurance in low- and middle-income countries: lessons from South Africa. In: Sagan A, Mossialos E, Thomson S, editors. Private Health Insurance: History, Politics and Performance. Cambridge: Cambridge University Press; 2020. p. 377–413.CrossRef
60.
Akokuwebe ME, Idemudia ES. A comparative cross-sectional study of the prevalence and determinants of health insurance coverage in Nigeria and South Africa: a multi-country analysis of demographic health surveys. Int J Environ Res Public Health. 2022;19(3):1766.PubMedPubMedCentralCrossRef
61.
Wang Y, et al. Sociodemographic inequalities in health insurance ownership among women in selected Francophone Countries in Sub-Saharan Africa. Biomed Res Int. 2021;2021:6516202–6516202.PubMedPubMedCentral
62.
Shamu S, January J, Rusakaniko S. Who benefits from public health financing in Zimbabwe? Towards universal health coverage. Glob Public Health. 2017;12(9):1169–82.PubMedCrossRef
63.
Zeng W, Lannes L, Mutasa R. Utilization of health care and burden of out-of-pocket health expenditure in Zimbabwe: results from a national household survey. Health systems and reform. 2018;4(4):300–12.PubMedCrossRef
64.
Prince RJ. Universal health coverage in the global south: new models of healthcare and their implications for citizenship, solidarity and the public good. Michael. 2017;14(2):153–72.
65.
Putnam RD. The prosperous community: social capital and public life. American Prospects. 1993;4(13):35–42.
66.
Deber RB, Forget EL, Roos LL. Medical savings accounts in a universal system: wishful thinking meets evidence. Health Policy. 2004;70(1):49–66.PubMedCrossRef
67.
McLeod H, McIntyre D. Undermining risk pooling by individualizing benefits: the use of medical savings accounts in South Africa. In: Sagan A, Mossialos E, Thomson S, editors. Private Health Insurance: History, Politics and Performance. Cambridge: Cambridge University Press; 2020. p. 414–45.CrossRef
68.
Mladovsky P, Mossialos E. A conceptual framework for community-based health insurance in low-income countries: social capital and economic development. World Dev. 2008;36(4):590–607.CrossRef
69.
Arai K. Trust and trustworthiness in the economy: how they function and how they should be promoted. Hitotsubashi Journal of Economics. 2007;48(2):225–40.
70.
Hall J, Fiebig DG, Van Gool K. Private finance publicly subsidized: the case of Australian health insurance. In: Sagan A, Mossialos E, Thomson S, editors. Private Health Insurance: History, Politics and Performance. Cambridge: Cambridge University Press; 2020. p. 41–64.CrossRef
71.
Sowa PM, et al. Private Health Insurance Incentives in Australia: in search of cost-effective adjustments. Appl Health Econ Health Policy. 2018;16(1):31–41.PubMed
72.
Turner B, Smith S. Uncovering the complex role of private health insurance in Ireland. In: Sagan A, Mossialos E, Thomson S, editors. Private Health Insurance: History, Politics and Performance. Cambridge: Cambridge University Press; 2020. p. 221–63.CrossRef
73.
Bhat N, et al. Zimbabwe’s national AIDS levy: a case study. SAHARA-J. 2016;13(1):1–7.
74.
Pillay TD, Skordis-Worrall J. South African health financing reform 2000–2010: understanding the agenda-setting process. Health Policy. 2013;109(3):321–31.PubMedCrossRef
75.
Basaza RK, O’Connell TS, Chapčáková I. Players and processes behind the national health insurance scheme: a case study of Uganda. BMC Health Serv Res. 2013;13(1):357.PubMedPubMedCentralCrossRef
76.
Agyepong IA, Adjei S. Public social policy development and implementation: a case study of the Ghana National Health Insurance scheme. Health Policy Plan. 2008;23(2):150–60.PubMedCrossRef
77.
Dieleman JL, Hanlon M. Measuring the displacement and replacement of government health expenditure. Health Econ. 2014;23(2):129–40.PubMedCrossRef
78.
Kabonga I. Dependency theory and donor aid: a critical analysis. J Dev Stud. 2017;46.
79.
Kim B, Lee I. Agency problems and performance of Korean companies during the Asian financial crisis: Chaebol vs. non-chaebol firms. Pac Basin Finance J. 2003;11(3):327–48.CrossRef
80.
Awoonor-Williams JK, et al. Does the operations of the National Health Insurance Scheme (NHIS) in Ghana align with the goals of primary health care? perspectives of key stakeholders in northern Ghana. BMC Int Health Hum Rights. 2016;16(1):23.PubMedPubMedCentralCrossRef
81.
Sodzi-Tettey S, et al. Challenges in provider payment under the Ghana national health insurance Scheme: a case study of claims management in two districts. Ghana Med J. 2012;46(4):189–99.PubMedPubMedCentral
82.
Hore R. Zimbabwe: are the costs of AIDS medical care affordable? AIDS Anal Afr. 1993;3(2):6–8.PubMed
83.
Zoidze A, et al. Promoting universal financial protection: health insurance for the poor in Georgia – a case study. Health Research Policy and Systems. 2013;11:45.PubMedPubMedCentralCrossRef
84.
Abiiro GA, Alatinga KA, Yamey G. Why did Ghana’s national health insurance capitation payment model fall off the policy agenda? a regional level policy analysis. Health Policy Plan. 2021;36(6):869–80.
85.
Issahaku Y, et al. Is value-based payment for healthcare feasible under Ghana’s national health insurance scheme? Health Research Policy & Systems. 2021;19(1):1–14.
86.
Abiiro GA, McIntyre D. Universal financial protection through National Health Insurance: a stakeholder analysis of the proposed one-time premium payment policy in Ghana. Health Policy Plan. 2013;28(3):263–78.PubMedCrossRef
87.
Brady D, et al. Path dependency and the politics of socialized health care. J Health Polit Policy Law. 2016;41(3):355–92.PubMedCrossRef
88.
Wilsford D. Path dependency, or why history makes it difficult but not impossible to reform health care systems in a big way. J Publ Policy. 1994;14(3):251–83.CrossRef
89.
Oliver A, Mossialos E. European health systems reforms: looking backward to see forward? J Health Polit Policy Law. 2005;30(1–2):7–28.PubMedCrossRef
90.
Koduah A, van Dijk H, Agyepong IA. Technical analysis, contestation and politics in policy agenda setting and implementation: the rise and fall of primary care maternal services from Ghana’s capitation policy. BMC Health Serv Res. 2016;16(1):323.PubMedPubMedCentralCrossRef
Metadata
Title
Inequality and private health insurance in Zimbabwe: history, politics and performance
Authors
Alison T. Mhazo
Charles C. Maponga
Elias Mossialos
Publication date
01-12-2023
Publisher
BioMed Central
Published in
International Journal for Equity in Health / Issue 1/2023
Electronic ISSN: 1475-9276
DOI
https://doi.org/10.1186/s12939-023-01868-9

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