Proposed health insurance scheme: A golden opportunity

Dr Augustine Mazvuru Correspondent
Zimbabwe is a developing country whose healthcare system is faced with a number of challenges. During the first decade of independence, the government focussed on equity and universal provision of healthcare.

Unfortunately this could only be until the World Bank inspired Economic Structural Adjustment Programme (Esap) of 1991, which scrapped the welfare-centred policies and reduced budgetary allocations to the health sector.

Since the early 1990s, the nation’s healthcare system has taken in the hammer-blow of a faltering economy and attendant complications such as low investment in infrastructure and the brain-drain of key personnel to foreign destinations.

The healthcare system is grossly inequitable with the privileged few having disproportionate access to healthcare while the poor and indigent are largely excluded.

More than 90 percent of Zimbabweans are not on any form of health insurance, hence the majority are supposed to pay out of pocket (OOP) when ill-health strikes.

Even those who might be under some health insurance cover often have to pay huge shortfalls and co-payments when seeking treatment.

To compound the problem, the 2013 Poverty and Poverty Datum Line Analysis in Zimbabwe Report shows that 70 percent of the population is poor and may thus face financial exclusion with regard to access to healthcare.

A study on access to healthcare services in Zimbabwe singled out user fees as a significant barrier to access to healthcare especially among the poor and vulnerable.

As a remedial intervention, the Government recently announced that plans were at an advanced stage to introduce a National Health Insurance Scheme (NHIS) as a basis for universal health coverage (UHC).

Despite the national significance of the scheme and its supposed imminence, so far, other than sporadic media statements by some government officials, not much is known about the proposed NHIS Bill in the public domain.

Ironically, what has been crystal clear and consistent is a growing chorus of resistance to the idea by key stakeholders such as labour and employer organisations.

What is Universal Health Coverage?

UHC refers to a situation where all individuals and communities receive healthcare services without suffering financial hardship.

Sustainable Development Goal 3.8 describes UHC parameters as “financial risk protection, access to quality essential healthcare services and access to safe, effective, quality and affordable essential medicines and vaccines for all.”

The World Health Assembly Resolution 58.33 of 2005 states that all people should have access to healthcare services, and while doing so, should not be subjected to the financial consequences of paying out of their pockets.

Tedros A Ghebreyesus, the new World Health Organisation (WHO) Director General, campaigned for the post on a vision of “a world where everyone can lead healthy and productive lives, regardless of who they are or where they live.”

There is a concern that when people pay user fees directly, they may end up using their life savings, borrow or sell their possessions, and in the process harm their future and, quite often, that of their children.

The general consensus is that raising health finances through some pre-payment arrangement is the most effective and efficient route towards UHC.

This works even better and is more sustainable when a large number of people pool their funds to cover everyone’s health costs.

At the core of UHC is the principle that access to healthcare services should be purely based on need and not the ability to pay.

Countries may pursue various ways of prepayment and pooling models but the principles and goals are generally not different.

The key issue is inclusivity.

The NHIS can be defined as a health insurance programme that is financed by taxes and administered by government to provide comprehensive healthcare that is generally accessible to all citizens.

The spicy Indian food

A year ago, the writer in the company of a friend named Tatenda visited Cochi, an Indian port city within the southwest state of Kerala.

Though the purpose of the visit was academic, Tatenda fell in love with spicy Indian food. He indulged and had severe gastritis which needed urgent medical attention.

Staff at our residency directed us to a local government district hospital where consultation and all medication were provided for free. We were so touched by the “free” service.

However, as economists say, there is no free lunch under the sun, we would soon learn that the Kerala government had pre-emptively set aside some money in anticipation of my friend’s need; access to care was not going to depend on whether he could afford the cost of treatment.

Had Tatenda been required to pay user fees before accessing treatment, some financial hardship, if not catastrophe, could have befallen him as he did not have much money.

There is no doubt that the majority of Zimbabweans can easily identify with Tatenda’s vulnerability when faced with a healthcare need.

The commonplace experience in Zimbabwe is that each time someone falls ill, family members, friends or neighbours end up getting financially involved.

Though this helps to redeem the situation, and indeed subscribes to the African values of ubuntu, there are often no guarantees and access to healthcare may either be delayed or missed on financial basis.

To ensure unhindered access to care, a health financing mechanism that eliminates user fees is essential.

The Statistics

In the 2016 national budget, the per capita health expenditure in Zimbabwe was US$24.

This falls way short of the World Health Organisation’s recommended level of US$34 and Sadc’s average of US$146.

This funding hiatus means much less is available for the requisite expenditure to sustain an acceptable coverage and quality of care.

The infant mortality of 75 per 1 000 live births is one of the worst in the world. According to the 2014 Zimbabwe Demographic Survey, 84 out of 1 000 children are likely to die before they reach the age of five years.

About 650 per 100 000 Zimbabwean women die during labour and this is much higher than the Sustainable Development Goals’ target of 174 per 100 000.

Infrastructure at public healthcare facilities is dilapidated; drugs and medicine stock-outs are rampant and persistent.

Perhaps the most tell-tale sign of the strain facing healthcare in Zimbabwe could be the recent spine-chilling report by the Zimbabwe Statistical Agency (ZIMSTAT) which estimates that less than 4 percent of the population will live beyond the age of 65 years.

According to the WHO (2016), Zimbabweans lag behind the world average life expectancy of 71 years by about ten years.

Tragically, literature has it that for every year reduced of life expectancy, a country’s GDP per capita is reduced by 4 percent.

The list of these negative indicators could be longer but it’s not all gloomy.

For instance, Zimbabwe has evolved to be a model in the fight against the HIV/Aids pandemic after the country succeeded in reducing its national prevalence from about 28 percent in 1999 to the current 14 percent.

Since the 1990s, the Government has been implementing a user-fees exemption scheme for children under five years, adults above 65 years and the poor between six and 64 years.

Despite the good intentions and potential, this policy has remained largely impractical due to a funding deficiency which leaves public healthcare facilities under resourced and unable to cope with demand for services.

 

This article is the first instalment in a series of articles by Dr Augstine Mazvuru under the title “The Proposed National Health Insurance Scheme in Zimbabwe: A Golden Opportunity amidst Stakeholder Resistance and Myths”

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