Online Reporter
Enock Musungwini
Zimbabwe’s medical aid industry is once again at the centre of a major regulatory debate.
The Government, medical aid societies, health service providers, Parliament, lawyers, regulators, key stakeholders and commentators are all speaking.
The issues are serious: whether medical aid societies should continue owning clinics, pharmacies, laboratories and hospitals; whether they should remain under Ministry of Health and Child Care regulation and oversight; whether they should move to Insurance and Pensions Commission (IPEC) regulation and oversight; whether risk-based capital should be introduced for medical aid societies; and whether Statutory Instrument 330 of 2000 remains fit for purpose in the 21st century.
Yet one voice remains strangely weak — that of the medical aid member. This member is also the patient, contributor, beneficiary, household budget holder and ultimate bearer of regulatory failure.
For many Zimbabweans, medical aid is not an abstract financing product. It is a monthly deduction from already strained income.
It is the expectation that on a rainy day when a child falls ill, a spouse needs surgery, a parent requires medication for chronic conditions or an emergency occurs, the medical aid card will work.
But too often that promise is uncertain.
Medical aid members face shortfalls, unclear benefit limits, rejected cards, pre-authorisation delays, limited information on exclusions, provider network restrictions, delayed claims and unexplained changes to benefits.
The problem is not only cost. It is powerlessness on the medical aid members.
Most actors claim to speak for members, yet the ordinary member remains peripheral, fragmented and tokenistically represented.
The illusion of member representation
Medical aid societies often argue that they represent members because they are member-based institutions with boards and governance structures. This claim should be treated with caution.
Internal representation on a board is not the same as independent member voice.
Board members may sit in structures where the dominant information, agenda-setting power, technical language and operational control sit with management and the institution itself.
Once inside the boardroom, a so-called member representative can easily become absorbed into protecting the institution rather than independently defending the member.
This is a classic governance problem.
The representative becomes closer to the organisation than to the constituency they are supposed to serve. That does not mean every board representative is captured or compromised. It means the current model is insufficient.
A board is responsible for institutional survival. A member association is responsible for member welfare. Zimbabwe urgently needs to separate these two functions.
The current regulatory
dilemma
Zimbabwe’s medical aid societies are currently regulated under the Medical Services Act and the Medical Services (Medical Aid Societies) Regulations, Statutory Instrument (SI) 330 of 2000.
This framework provides for registration, governance, waiting periods, claims settlement, solvency, unfair practices, audits, dissolution and some complaints handling. However, the framework was built for a different era.
It has not fully kept pace with vertically integrated medical aid groups, related-party transactions, complex benefit design, digital claims systems, rising shortfalls and modern consumer-protection expectations.
The current debate has focused heavily on vertical integration. Those supporting prohibition argue that medical aid societies should not be both funders and providers.
They argue that ownership of clinics, hospitals and pharmacies may create conflicts of interest, encourage self-referral, restrict patient choice, create opaque internal pricing and allow societies to prioritise their own facilities over independent providers.
These concerns are legitimate.
No member wants a system where the funder, provider, referee and scorekeeper are effectively the same institution. However, the opposing argument also deserves attention.
Medical aid societies argue that their facilities emerged partly because independent providers were rejecting medical aid cards, charging huge and unaffordable shortfalls, demanding cash upfront or leaving members without affordable options.
Some members may indeed have benefited from medical aid-owned facilities where costs were lower and cards were accepted.
Therefore, an abrupt ban on vertical integration may not automatically protect members.
It could also remove one of the few affordable service options available to some members.
The real question is not whether vertical integration is always good or always bad.
The real question is: What regulatory arrangement best protects members from exploitation, denial of care, huge and unaffordable shortfalls, restricted choice, poor quality and institutional conflicts of interest?
The Ministry of Health, IPEC or a new health-focused independent authority?
Keeping medical aid societies under the Ministry of Health and Child Care has strong logic. Medical aid is not ordinary insurance.
It is linked to universal health coverage, health rights, access to care, benefit design, treatment pathways, provider tariffs, quality of care, public health priorities and universal health coverage.
A health sector regulator is more likely to appreciate the meaning of chronic care, emergency care, primary health care, clinical exclusions, referral pathways and patient harm.
However, the weakness of the current arrangement is equally clear.
Regulation through a ministry department may lack sufficient autonomy, actuarial capacity, health economics expertise, legal enforcement strength, consumer protection infrastructure, market conduct surveillance tools and public data systems to oversee an industry estimated to US$400 million annually.
Regulation requires more than the existence of laws. It requires enforcement independence, complaint adjudication, solvency monitoring, inspections, sanctions, public reporting and consumer education.
Moving medical aid societies to IPEC also has advantages.
IPEC has experience in prudential supervision, solvency, risk-based capital, governance, compliance and financial market conduct.
This expertise could strengthen financial discipline and protect members from scheme failure. Yet medical aid is not simply a financial product.
If regulation is treated mainly as insurance supervision, Zimbabwe may overemphasise solvency while under emphasising access, benefit adequacy, provider relations, health equity, patient rights and universal health coverage.
Zimbabwe should, therefore, avoid a false choice between the Ministry of Health and IPEC.
The better option is a dedicated, independent or semi-autonomous medical aid and private health insurance regulatory authority.
This authority should be health-focused but prudentially strong, with expertise from health economics, actuarial science, public health, law, clinical practice, consumer protection, employers, labour, Government, policy analysis and independent member representation.
Global and regional
lessons
The World Health Organisation’s guidance on engaging the private health sector for universal health coverage argues that countries need to harness private sector contribution while retaining public stewardship, accountability, quality assurance and financial protection.
In other words, the private sector can contribute to universal health coverage only where the Government can govern the whole system in the public interest.
South Africa provides a useful regional lesson. The Council for Medical Schemes is an autonomous statutory body established under the Medical Schemes Act 131 of 1998 to regulate medical schemes and protect beneficiaries.
It has a registrar, council structures, technical units, complaints processes, prescribed minimum benefit oversight, consumer education and public-facing information.
Importantly, beneficiaries and aggrieved persons can submit complaints to the registrar’s office after first attempting to resolve matters through the scheme’s internal process.
Australia offers another useful example.
The private health insurance ombudsman based in New South Wales protects the interests of people covered by private health insurance by taking complaints, providing information and helping resolve disputes involving insurers and healthcare providers.
The office also publishes private health insurance complaints updates, trends and learning points.
The lesson for Zimbabwe is simple: Members should not have to rely only on the medical aid’s internal complaints process.
There must be an independent, objective and non-conflicted place to go.
Recommendations
In my view, Zimbabwe’s reform debate is incomplete because members are spoken about more than they are directly heard.
The law should establish an independent medical aid members and patients association of Zimbabwe. This should be a membership-based body separate from medical aid societies, providers and regulators. Its role should be to represent members in policy consultations, tariff debates, benefit design discussions, complaints reform, parliamentary hearings and regulatory review processes.
Second, any future regulator should have statutory seats reserved for independent member and patient representatives, not only industry nominees. These representatives should be elected or nominated transparently, trained in health financing and protected from institutional capture.
Third, Zimbabwe needs an external medical aid complaints and appeals mechanism.
Members should be able to complain about shortfalls, rejected cards, unclear benefits, delayed authorisations, unfair exclusions, non-payment of claims, network restrictions and poor disclosure.
Complaint statistics should be published regularly by medical aid, complaint type, turnaround time and outcome.
Fourth, every medical aid society should be required to publish benefit schedules in plain language.
Members must know what is covered, what is excluded, what requires pre-authorisation, what co-payments apply, which providers are in-network, how shortfalls are calculated and how to appeal against decisions.
A benefit that is not understood is not a benefit; it is a promise wrapped in uncertainty.
Fifth, vertical integration could be regulated through strict safeguards before any drastic prohibition is implemented.
These safeguards should include full disclosure of related-party transactions, arm’s-length contracting, independent pricing, member choice, equal treatment of independent providers, published claims settlement timelines and regulatory approval of ownership structures.
If disinvestment is required, it must be phased, evidence-based and accompanied by member access-protection plans.
Zimbabwe’s medical aid money belongs morally, and often practically, to members.
Medical aid societies manage it.
Providers claim from it.
Employers contribute to it.
Regulators supervise it.
But members carry the risk when the system fails. Reform must, therefore, begin with the member’s voice, not end with it as an afterthought. The industry does not only need stronger regulation. It needs democratic health financing accountability.
A medical aid card should not be a symbol of uncertainty. It should be a reliable promise of protection, dignity and access when illness comes.
The missing voice must now become the central voice.
Enock Musungwini is a public health and policy specialist and a PhD in Public Health candidate specialising in health policy and financing at UNICAF University. He wrote this article in his personal capacity. Contact details: [email protected]
