Table 2 A timeline of the origins and development of PHI in Zimbabwe: 1930–2022

Colonial period: 1930–1979

• 1930: Public Service Association appoints a special committee to start the Public Service Medical Aid Society (PSMAS)

• 1939: Resolution submitted to the Rotary Club of Salisbury advocates for MAS to deal with “cases of distress caused by illness due to unaffordability of health care.”

• 1940–1944: Slow progress to expand MAS due to World War II. Black and Asian teachers are barred from joining PSMAS

• 1945: The Commercial and Industrial Medical Aid Society (CIMAS) begins operations

• 1946: The Representative Council of Medical Aid Societies of Southern Rhodesia is formed with a mandate to establish collaborative ties with the Rhodesian branches of the British Medical Association

• 1947: Matabeleland representatives secede from the MAS

• 1952: Black and Asian government employees are admitted into PSMAS

• 1953: Under the leadership of Ian Smith, the Parliamentary Select Committee considers expanding MAS to rural areas

• The late 1950s–1970s: Growth is observed in the population covered by MAS

• The early 1970s: Concerns are raised over escalating costs for MAS and doctors’ demands for increased reimbursement fees 

• 1978: The short-lived Zimbabwe-Rhodesia settlement government led by Bishop Abel Muzorewa declares that the expansion of medical aid to Blacks is a priority

Post-independent Zimbabwe: 1980-present (2022)

• 1980: Zimbabwean government inherits a dual and racially divided health care system that favors the White minority population

• In the early 1980s: Most whites continue to seek membership in MAS. A growing number of dominantly urban and elite Blacks became members of MAS mainly due to mandatory PHI for those with formal employment

• The late 1980s: About two-thirds of the resident Europeans, but less than one percent of the African population, possess health insurance  coverage

• The early 1990s: Weak economic performance and perceived unsustainability of public sector subsidies leads to market-oriented health sector reformation, including participation of private insurers

• The mid-late 1990s: There is continued interest in diversifying revenue sources for the health sector in Zimbabwe. PHI is considered a viable alternative

• The 2000s: Weak economic performance, unsustainable medical inflation, and escalating reimbursement costs threaten the viability of MAS, which then turn to various market survival strategies. The period also features increased capital flow toward MAS

• 2000: The Medical Aid Societies Registration Act is created to regulate the societies’ registration and conduct

• 2003: PSMAS launches Premier Service Medical Investments (PSMI) and begins to implement the “Blue Ocean Strategy” to acquire health facilities through vertical integration. During the same period, CIMAS introduces “managed care ideals.”

• 2003: The Zimbabwe Medical Association (ZIMA) forms the New Independent National Tariff and Liaison Committee to establish fees, independent of MAS, due to the differences between AHFoZ and ZIMA on fee levels and delays in reimbursements

• 2010–2013: Notable stabilization in economic performance and growth in the number of MAS. Insurance coverage reached an all-time high of 14% during the period

• 2014–Present (2022): A deteriorating economic environment and a decline in medical society coverage (to around 10%). The period was marked by escalating and recurrent fee wars between ZIMA and insurers. Further vertical integration between MAS and providers