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Dr Augustine Mazvuru Correspondent
Right from the early years of independence, government’s policy documents on healthcare expressed a profound orientation towards equity and access for all citizens. In 1980, a US$150 income based exemption was introduced to cushion and guarantee low-income earners access to healthcare. The Ministry of Health and Child Welfare (MoHCW) promulgated the Planning for Equity in Health policy in 1984. This was closely followed by the Health for All Action Plan 1985-90. To help maintain the focus, the aura of the new millennium was “christened” with an ambitious national vision: “Health for All by Year 2000”.

However, like pieces of dry wood in an inferno, these lofty ideas were consumed to smithereens by the fire of neo-liberal capitalist market-orientated economic reforms of the early 1990s. In earnest, the Government started to enforce the systematic collection of user fees at all health facilities at the inception of the Breton Woods’ ESAP in 1991.

In his 1996 article contribution to the Sustainable Health Care Financing in Southern Africa, TA Zigora, (former Deputy Secretary of Health), posited that there was a compelling reason to introduce an inclusive health insurance scheme for Zimbabwe.

His arguments were premised on the proviso that healthcare was out of reach of many because the majority could not afford user fees. He further noted that financing from private health insurance was skewed in favour of a small section of the population while the less fortunate were left to their own means.

Zigora, however, could not be too confident of the prospects of an NHIS, citing the likelihood of stakeholder opposition as an impediment. True to this early postulation, calls by the government to introduce the scheme as a basis for Universal Health Coverage (UHC) have received fierce resistance from key stakeholders.

The pivot of rejection has been the anxiety about an additional tax burden on an already heavily taxed worker, and a deep seated fear that this NHIS may turn out to be another fertile garden for corruption as has been witnessed in a number of state institutions. While these concerns may not be misplaced, the begging question is: do we have a better option?

Seventy years ago

In 1946, the British Health Secretary Aneurin Bevan introduced the National Health Service (NHS) as part of the post-Second World War socioeconomic reconstruction agenda. The 1939-1945 war had battered the economy and many were poor and without jobs.

The NHS sought to reduce inequality on access to healthcare through the amalgamation and better coordination of a myriad regional public and private health systems which were in existence.

Despite the social justice and equity thrust of the NHS, there was widespread resistance and resentment towards the scheme at inception. Many stakeholder groups including municipal authorities, charities, churches and doctors did not believe the NHS was a good idea.

After the publication of the NHS Bill, one former chairman of the British Medical Association (BMA) compared the whole idea to a dictatorship under Hitler. Many equated the introduction of the NHS to the socialism that dominated Eastern Europe back then. However, Bevan soldiered on; he made a number of compromises to accommodate competing views and today the NHS in Britain is a global icon envied by many. Put simply, every man, woman and child in the UK is guaranteed access to healthcare without necessarily having to pay user fees.

Other than the UK, Zimbabwe can learn invaluable lessons from many other countries around the world which made a bold decision to embark on the UHC for the sake of their citizens. Leading examples in Africa include Ghana and Rwanda.

Getting inspiration from the Constitution

Meanwhile, Zimbabwe is party to and has ratified a number of international and regional human rights conventions which recognise the right of all citizens to healthcare. The provisions of these extra-territorial conventions have been domesticated through section 34 of the 2013 Constitution.

The right to health is categorically provided for in section 76 which states that “every citizen and permanent resident of Zimbabwe has the right to have access to basic healthcare service”. This constitutional provision is a culmination of long-held views on the essence of social justice and equitable healthcare.

However, its significant point of variation is perhaps the illumination it gives on the notion that health is no longer a privilege but a fundamental right which the State of Zimbabwe should deliver to all its citizens.

In the same manner policing and fire-fighting are free services provided for all, the new Constitution demands that healthcare is every citizen’s right.

Ethically, the Constitution seeks to deliver distributive justice in terms of resource allocation, but legislation alone cannot address the acute funding deficiency and inequitable access besieging the health sector.

For this reason, it is imperative that an effective health financing mechanism is adopted to serve as a link between a constitutional dream and reality. The constitutional declaration that healthcare is a citizen’s right should be a principle on which the NHIS is anchored.

The NHIS should not be viewed through the same lenses as the existing medical aid insurance entities because of a diametric difference on philosophical underpinnings. While the former is about “citizens,” the latter is about “members”; and again, while the former is about delivering a “right”, the latter is about delivering “privileges” to those who can afford them.

This dichotomy defines a fundamental dimension that should guide the implementation of the NHIS. In fact, there is a risk that those who are already insured could be unilaterally leading the current debate on the NHIS while prospective beneficiaries particularly the poor are on the side-lines.

To avoid self-serving biases, discussions around the NHIS should be enriched by the views of those who are not insured. After all, they understand better the agony and tribulations and sometimes the humiliation of having your family go through life without health cover.

Other debates

Current relations between service providers and a mélange of medical aid societies serving less than 10 percent of the population are rather cold. There is often friction and at times full blown hostility. Doctors are calling for stricter regulation of medical aid societies citing poor reimbursement of claims and corporate governance shortcomings.

On the other hand, the societies are accusing doctors of over treatment and fraudulent claims and have decided to compete in the provision of healthcare through vertical integration. However, no matter how loud these contestations may be, even at global level, the scope of private insurance is quite limited when it comes to UHC.

Of all 154 low-income and middle-income countries, only 11 fund more than 10 percent of their healthcare through private health insurance. Furthermore, without adequate regulation, the business model adopted by most private insurers is called “cream-skimming”, where focus is on lower-than-average risk membership.

This consequently disadvantages needy groups such as the elderly and people with chronic conditions. Also, parallel to the NHIS debate are calls for the government to introduce earmarked pools such as the Cancer Levy and the Road Accident Fund.

While the idea behind these funds may be noble, what is limited is their impact on universal healthcare as they are more of piece-meal remedies against a wider challenge. Great care needs to be exercised so that narrower perspectives do not overshadow the need to establish a population-based healthcare system. A successful NHIS can suffice and exceed the capacity and scope of several small funds combined.

Getting decided: mandatory or voluntary?

As the powerful and influential ferociously opposed Aneurin Bevan in 1946, the British Secretary of Health chose to stand for a better future of the majority of citizens. The minister in-charge of the NHIS Prisca Mupfumira should make good choices, lest posterity shall judge her harshly.

So far there has been some equivocation. The public was initially informed through the media that the NHIS was going to be a “mandatory” scheme for all, but this position recently shifted to “voluntary”, after some interest groups opposed and threatened to rock the ship.

While this is understandable within the dynamics of stakeholder consensus, two risks of making the NHIS a voluntary scheme may need to be considered.

Firstly, despite its high sounding name, a voluntary NHIS is likely to be no different from the member driven societies already in existence. Or it could actually be worse off. The 2010 World Health Report precisely states: “it is impossible to achieve universal coverage through insurance schemes when enrolment is voluntary.”

The argument is that those who are well-off and healthy are likely to opt out and there won’t be sufficient funds to cover the poor and unwell. Nothing can be worse than having the NHIS as a scheme for poor people.

The pillar of insurance is risk sharing through pooling of resources. Within the context of a healthcare insurance scheme, it is critical to have a good number of healthy individuals to subsidise the costs of members who are not well and are seeking treatment. There is strength in numbers.

At more than 70 percent coverage, Ghana boasts of one of the most comprehensive NHISs in sub-Saharan Africa and its key design principle is “risk equalisation” where the financial risk of illness is equally shared among all citizens.

The law in Rwanda stipulates that “any person residing in Rwanda shall be bound to health insurance”, thereby making affiliation to the Rwandese equivalent of NHIS mandatory. As a result, the Rwandan scheme covered more than 92 percent of the population hardly ten years after its inception in 1999.

Secondly, a voluntary NHIS will simply add to the challenge of acute funding fragmentation that already exists within the health insurance landscape of Zimbabwe. A fragmented health insurance environment limits the scope for cross-subsidisation, leads to high administrative costs and causes unnecessary duplications.

More than 30 health insurers are already in a dog fight for a relatively small market, serving less than 10 percent of 14 million citizens. If the proposed NHIS unscrupulously adopts the model of these health insurers, the vultures will be many for a carcass of a rat.

Twelve years after introducing a voluntary NHIS in Nigeria, only 3 percent of the population got covered. Literature is indeed awash with stories of failed NHISs across continents. To avoid failure, there is need to draw lessons from those who have succeeded and of course avoid the dreadful mistakes made by forerunners.

Dr Augustine Mazvuru is a former board Chairperson of Gutu and Morgenster Mission Hospitals. He is a doctoral candidate focussing on Universal Health Coverage. This article is written in his personal capacity. For feedback – email address: [email protected], cell : +263 7122 34300