Editor’s Memo

Can we trust Nssa with our health?
Vincent Kahiya

DOES anyone remember the National Social Security Authority (Nssa)’s plan last year  to set up a  National Health Insurance Scheme to improve equity in access to family health-care throug

h a prepayment scheme?

We were told by the National Health Insurance Scheme (NHIS) committee chair James Matiza that the scheme would equip rural health centres, municipal clinics and general practitioners accredited by the Ministry of Health with machinery, drugs and other essential facilities for the benefit of NHIS members. The plan was immediately denounced by civic groups and labour, and rightly so because Nssa does not have a good record of accounting for the billions it collects from employers and employees in the name of social security.

The issue of national insurance crossed my mind this week with the announcement by the Health ministry that it had raised hospital consultation fees to between $400 000 and $1 million from $300 to $500.

Health deputy minister Dr Edwin Muguti was quoted by the Herald as saying “when people are not paying they tend to abuse facilities but when they pay, hopefully they will become more responsible”.

But is it not the government which has abused health facilities by failing to adequately fund them while pursuing populist policies in the pricing of health services? Muguti’s ill-conceived stance that shock treatment to patients will improve health delivery is as hopeless as the idea of Nssa setting up a national health insurance scheme under the current inflationary environment.

Commenting on the proposed scheme last year Mike Bimha, the president of the Employers’ Confederation of Zimbabwe said: “We need to get our economy right. Unless we turn the economy around the benefits from any scheme will be insignificant.”

It will not work as long as investment in insurance is eroded by inflation and as long as government has no predictable system of raising hospital fees.  I can imagine the impact this week’s increase in hospital fees would have had on a public health insurance scheme.

And such a health insurance scheme can only work well when there is adequate funding of the health sector by the state. This is the biggest problem for Zimbabwe. Public-sector funding for health has become inadequate and former co-operating partners have reduced funding in protest at government policies.

Five years ago private spending constituted 50% of total national health expenditure, whilst public spending and donor funding constituted 37% and 13% respectively.

In the 1980s, it was estimated that the government was the biggest institutional financier of the health sector services. However, recent estimates suggest that individuals coupled with private health insurance benefits now fund the greatest portion of health services. Studies show that in Zimbabwe in 2001, an estimated 10% of the population purchased private cover, accounting for 23% of total health expenditure. Private health expenditure is now even larger as those in formal employment seek medical aid cover to get treatment at private health institutions.

It is significant that those on private medical cover will seek treatment at private institutions first and only go to public hospitals if the medical cover is insufficient to pay fees at the private health institutions. Poor quality of service is the main cause people shun public hospitals. It is estimated that medical aid societies are making at least 75% of insurance payments to the private health sector, benefiting a small portion of the society in formal employment.

The idea of a national health insurance scheme was thus conceived to address equity concerns arising from the flow of funds in the health sector as a whole.

But there is another problem. Zimbabwe has a large informal sector, which makes tax collection difficult. This will be a major handicap in collecting sufficient revenues to fund social insurance systems to provide broad financial protection for health care.

The fear is having those in formal employment — who are already paying large sums of money to private medical aid firms — being forced to pay another tax to finance a health scheme to also benefit informal-sector employees who have for years escaped the tax net. I do not believe Nssa or the Health ministry are up to this task of safeguarding our health. The record speaks for itself.