The Public Service Medical Aid Society (PSMAS) in Zimbabwe: A historical overview and its suggested role in achieving national health insurance (NHI)

Abstract

This paper openly critiques the history and policies of the Zimbabwean Public Service Medical Aid Society (PSMAS) for their lack of standing as the foundational launching platform of the proposed National Health Insurance (NHI) Scheme. Instituting a very thorough qualitative desk review of peer-reviewed literature, government documents, audit reports, and media analyses from 2019-2024, the paper utilizes the WHO Health Systems Building Blocks Framework and theories including Strategic Purchasing, Governance, and Principal Agent to diagnose institutional viability. The study also utilizes health financing models and the path dependency theory, which suggests that past decisions and events can have a significant impact on current and future outcomes, even if those decisions were made under different circumstances. This theory helps to explain how the history and policies of PSMAS have influenced the current state of the proposed NHI Scheme in Zimbabwe. The account draws on convincing evidence divulging that PSMAS has been allowed to decline down the crevice of systemic collapse marked by governance fraud of about US$40 million as reported by the Zimbabwe Anti-Corruption Commission in 2022, hard liquidity crises with US$47 million in contribution arrears, and operational breakdown indicating 72% of members getting scared of being denied such access by unfriendly providers blacklisting them. Meanwhile, Zimbabwe's NHI policy is a work in progress, and the disconnect between the "broad contours" of the NHI policy versus an initially promising program promises that a further relationship could be established to finance actuarial models suggesting the crop of proposed financing items needed considerable review, namely the NHI's ability to cover Zimbabwe's huge remaining informal sector workforce. The study argues that the basic vulnerabilities from past institutional failure vis-a-vis PSMAS and path dependency count as an existential threat for any NHI built from its structure. The narrative is one of the safeguarding stances: fundamentally rethinking a dead horse instead of propping it up yet again, and PSMAS finds itself to be the flagship of the NHI. This notion is fundamentally unattractive. Recommendations call for a holistic approach to the effectuation of a proper NHI framework. This framework, thus, sees first-order calls of law having an enactment of a dedicated NHI Act, establishing a new purchasing agency, and phase-wise action that insulates the national scheme from PSMAS legacy liabilities.