By Catherine Murombedzi
Zimbabwe’s medical aid societies are facing fresh accusations that they have turned from financiers of healthcare into its biggest competitors. Doctors say this is squeezing independent practitioners out of business and leaving patients with fewer choices.
As Parliament prepares to examine proposed amendments to Statutory Instrument 330 of 2000 (Medical Services – Medical Aid Societies Regulations), practitioners argue that a stopgap born of the economic meltdown has hardened into a monopoly.
During the hyperinflation of the early 2000s, medical aid societies often delayed or defaulted on claims. Private doctors demanded cash upfront from patients. Several societies responded by opening their own clinics and diagnostic centres to cushion members.
Two decades on, critics say the emergency measure has outlived its purpose. Societies now own hospitals, clinics, pharmacies, laboratories and diagnostic centres, directly competing with the providers they are supposed to pay.
Public health leader Professor Johannes Marisa said the boundaries of SI 330 “have been stretched” over two decades. He said funders have moved beyond their financing role to become direct service providers.
Dr Vivek Solanki, founder of Trauma Centre Borrowdale, questioned how non-profit societies could generate enough surplus to build hospitals and laboratories while private operators pay taxes.
“Medical aid societies are non-profit-making organisations, right? So they’re not supposed to make profit. Now, how is it that they make profits enough to build hospitals, clinics, radiology services, laboratory services? Yet private hospitals that are owned by other individuals have to pay taxes. So how can they compete on equal ground?” he said.
He traced the trend to the early 2000s, when Premier Service Medical Services opened dental, optometry and pharmacy outlets, clinics and a hospital nationwide.
“Since it was a government parastatal, it was overlooked. Cimas followed suit, with FML and Alliance,” he said, adding that profit-making entities run by non-profit funders deny the Zimbabwe Revenue Authority a tax base.
A senior doctor who spoke on condition of anonymity said the conflict is structural. “When the entity determining whether a medical claim is valid and setting the payout tariff is the same entity owning the clinical facility receiving those funds, the referee and the player become one.”
Independent providers say societies have failed to implement tariffs gazetted by the regulator in 2014, leaving them reimbursed at rates more than a decade old while claims payments are delayed.
Dr Solanki described a vicious cycle. “The diminished market is created by the medical aid societies in which doctors cannot survive, then the same medical aids will employ those doctors in their clinics, their laboratories, the hospitals, for a very low salary. The very people who create the demise are the ones who are going to employ you.”
Inside funder-run facilities, a junior doctor working anonymously alleged that clinical decisions are being driven by finances.
“We are forced to practise corporate math, not medicine. We are ordered to see many patients within strict time limits and prescribe only the cheapest drugs available to protect corporate margins. If you order an exhaustive investigation for a critical patient, you are reprimanded,” he said.
Several practitioners, speaking anonymously, said they have little choice but to stay because the market is so constrained.
Doctors also allege that members are being steered toward society-owned facilities. Dr Solanki pointed to a recent bulletin from Cimas urging members to use its facilities.
“The fact that patients are literally forced, and as you can see, the bulletin recently sent out by Cimas, insisting that patients go to their facilities and not other facilities, is a case in point. Of course, they want to send their own clients to their own hospitals. This is all about control,” he said.
Members are also feeling the pinch. Juliet Mukanyamira of Mufakose said she received no benefit last year despite not making a single claim. “In January we would get rebates, now it’s shortfalls. I did not use my insurance so I expect to have saved,” she said.
Dr Solanki also criticised the funding of medical referrals to India, Turkey and South Africa, saying some procedures are available locally, even at Parirenyatwa Hospital. He said this raises questions over commissions and local underinvestment.
Cimas rejects the suggestion that its model is anti-competitive. Cimas Health Group Chief Marketing Officer Manatsa Gaka said its investments in facilities “improve access, containing costs, providing predictable tariffs and reinvesting resources in healthcare capacity.”
He said the model is not unique to Cimas, noting that at least five other societies run similar arrangements. He said it emerged because many providers refused medical aid cards during hyperinflation. “Medical aid societies consequently developed integrated facilities to preserve continuity of care,” he said.
Gaka said independent providers remain central to the system. “Approximately 75% of Cimas claims payments go to external service providers, compared with 25% paid to Cimas-related facilities.”
He conceded that vertical integration needs proper oversight but said it is not inherently anti-competitive. “Legitimate concerns should therefore be addressed through ring-fenced governance, transparent related-party arrangements, fair provider accreditation, tariff oversight and competition regulation, rather than a blanket prohibition that could reduce capacity and increase costs for members,” he said.
Cimas Chief Operating Officer Thando Kembo told the Parliamentary Portfolio Committee on Health in April that a law barring societies from owning hospitals and clinics could raise costs, cut benefits and reduce access.
The Committee on Justice, Legal and Parliamentary Affairs, chaired by Hon. Edson Zvobgo Junior, is set to begin examining the proposed amendments to SI 330.
Opponents of divestment warn it could violate property rights and discourage investment in the health sector. Reform advocates counter that divestment does not mean closures. They say banks, insurers, investment groups or international hospital networks could take over the facilities and run them as taxable commercial entities.
The reformers want societies restricted to funding and risk pooling, existing facilities unbundled into independent entities, premiums reinvested locally, and a statutory National Tariffs Liaison Committee to set reimbursement rates.
Medical aid societies cover only about 5% of the population, yet there are between 36 and 42 of them.
Doctors also ask whether, if societies can own clinics and hospitals, practitioners should be allowed to own medical insurance too.
