Navigating the path to universal health coverage: A comprehensive framework for the implementation of national health insurance in Zimbabwe

Abstract

Universal Health Coverage (UHC), which provides all people with necessary health services, has not been achieved in Zimbabwe because government health funding remains below 4% of Gross Domestic Product (GDP). The research creates an extensive method for implementing Zimbabwe's National Health Insurance (NHI) program, a road map to achieve Universal Health Coverage (UHC), which currently exists as an aspirational legislative requirement yet remains pending. The researchers used a qualitative comparative case study research design to carry out qualitative analysis through document reviews together with a comparative evaluation of health insurance systems from Kenya, Ghana, and Rwanda to identify problems within the national health financing system, which exists in a state of emergency. A systematic documentary review of Zimbabwean policy documents, which included the NHI Act, the National Health Strategy 2021-2025, and budget statements from 2019 to 2024. For Kenya, sources such as NGO reports and census data were utilized for the systemic review. In Ghana, sources used for the review include World Bank reports and health surveys, which provided valuable information. Rwanda's sources that were systematically reviewed include conflict resolution reports and economic development studies. Zimbabwe's health expenditure shows a strong dependence on out-of-pocket costs, which make up 34% of total health expenditures, while government health funding operates at less than 4% of Gross Domestic Product (GDP). This then creates financial disasters for 30% of households and produces extreme differences in healthcare access. The proposed framework creates three distinct phases for a ten-year transformation process, which includes foundational piloting (Years 1-3), national expansion (Years 4-6), and maturation and integration (Years 7-10). The main changes involve creating an independent NHI Fund through statutory requirements, implementing biometric IT systems, requiring formal sector payroll payments, developing a subsidized hybrid system for informal workers, and moving to capitation and diagnosis-related group (DRG) payment systems through strategic purchasing. The framework evaluation process uses a critical approach to assess organizational risks, which include two major threats: financial sustainability challenges from the high level of informal employment (76% of employment) and governance risks through corruption, which regional situations demonstrate. The NHI legislation needs transformation through an evidence-based phased approach that focuses on financial sustainability and governance strength and equality to become the main element of Universal Health Coverage in Zimbabwe.