In this cross-sectional study, we analysed access to health insurance in Zimbabwe and some associated factors. Access to health insurance could serve as a proxy to access to quality and timely healthcare [9], which is a basic human need and right. This access is not always possible in settings where there is no comprehensive health insurance and reduced disposable income. Zimbabwe has been battling hyperinflation and high levels of unemployment over the past decade to two. The United Nations’ Agenda for sustainable development agenda 2030 places Universal Health Coverage as an integral component for attaining the sustainable development goals, especially number three, by 2030 [6]. Countries that earlier on noticed the need for national health insurance schemes provide better healthcare to their populations. In their report ‘Fair society, Healthy lives”, Marmot et al described the concept of proportionate universalism, recognising the need for comprehensive approaches that prioritise those at the bottom of the social hierarchy to enable them to access quality services too [10].
The deteriorating health standards in Zimbabwe call for urgent investigation into nonparticipation in health insurance schemes among the Zimbabwean population. The Zimbabwe Demographic Health Survey (ZDHS 2010-11) showed that only 6% of the population was covered by health insurance in Zimbabwe [11]. Our analysis of the 2015–2016 data revealed poor access to health insurance as only 11% of 7397 females and 12% of 7420 males included in the analysis had access. Our findings corroborate various other studies conducted on the subject. For instance, level of education, income and age were factors associated with access to health insurance Gweru, the third largest city in Zimbabwe [4]. Level of education and wealth quintile were also reported as factors associated with access to health insurance in a study conducted in Harare, Zimbabwe’s capital city [12]. There is an urgent need to address access to health insurance in Zimbabwe. Other countries within the region have successfully implemented Community Based Health Insurance (CBHI) [13, 14]. Community-based health insurance (CBHI) schemes are voluntary and characterized by community members pooling funds to offset the cost of healthcare [14]. Further research that investigates the feasibility, acceptability and sustainability of CBHI as an alternative to pooling risk and financing social protection in Zimbabwe is warranted [8].
There was no statistically significant association between HIV status and access to health insurance in this study. A smaller proportion of HIV positive males (10%) had access to medical insurance compared to their HIV negative counterparts (12%). While it is good that there is equal access to health insurance between HIV positive and negative individuals, the role of OOPs as a barrier for healthcare access and adherence to ART [15], should not be ignored. Zimbabwe has generally seen success in the HIV continuum of care services with 97% of adults living with HIV/AIDS being on antiretroviral therapy [16]. This good ART coverage has significantly improved health and wellbeing of people living with HIV/AIDS (PLHIV). The provision of ART drugs free of charge has increased access to care and treatment for PLHIV. However, other indirect costs related to care (such as transportation, loss of income and food) and cost for care for other non-HIV related services that are not sponsored, and instead are financed by patients through OOPs remain high and represent a financial barrier for health care access [17–19].
A multi-sectoral intersection is required to identify and enhance means of improving health insurance coverage for the generality of Zimbabweans, taking into consideration the prevailing harsh socioeconomic conditions. Universal Health Coverage is essential to significantly improve health outcomes. However, insurance alone without improving the public health sector may not be alone. The public health sector in Zimbabwe has largely been reported as fragile, and unable to cater for the needs of the population in times of distress as was witnessed during the COVID-19 pandemic [20]. The pooling of funds through the National AIDS Levy to cater for some of the needs of PLWHA is evidence that with commitment, schemes can be set up that will enable the population to access quality and timely healthcare [21].
In the current COVID-19 era, provision of essential health services in public health facilities, including HIV and TB care, maternity care and care for patients with other chronic diseases has gone down substantially by an estimated 90% [20, 22–24]. Additionally, public health services which are principally utilized by individuals with no health insurance have over the years suffered from neglect and under investment with a poorly motivated health force [25]. The better equipped and manned private for-profit health facilities are usually patronized by individuals with health insurance. For example, COVID-19 treatment private facilities are turning away individuals with no health insurance whilst the public health facilities which take individuals with no health insurance are full and overwhelmed and unable to take on new patients. Since the majority of Zimbabweans don’t have medical insurance the Zimbabwe Ministry of Health and Child Care must make appropriate steps to increase funding for such facilities so that some of its citizenry do not fall through the cracks as they fail to access health care.