Dumisani Mugari
EVERY time Zimbabwe’s medical aid regulations come up for review, one accusation quickly dominates the conversation: “If co-payments and shortfalls are rising, medical aid societies must be failing at prudential management.”
It is a convenient conclusion— and in many cases, the wrong one. The uncomfortable truth is that shortfalls are often the predictable outcome of a market where many service providers operate without a gazetted, uniform tariff system.
When providers can charge widely different prices for the same service, a medical aid that pays consistently and fairly across its membership will inevitably leave a gap somewhere.
That gap is the so-called shortfall. This matters because Zimbabweans are already heavily exposed to out-of-pocket health costs.
A recent Afrobarometer dispatch (May 2025), citing the Community Working Group on Health, reported that only about seven percent of Zimbabweans have medical insurance, meaning the vast majority pay cash when they are sick.
In that context, unpredictable pricing—where two providers can charge very different fees for the same service—does not just create shortfalls; it creates avoidable financial shocks for households. A shortfall is simply the difference between what a provider charges and what a society reimburses under its benefit tariff.
That benefit tariff is not an arbitrary invention designed to “underpay” doctors; it is a governance tool for managing a shared pool of contributions.
Medical aid societies exist to spread risk and cost across members. If they reimburse the same consultation at wildly different levels depending on which doctor a member happened to visit, they would be privileging some members over others for identical care—and draining the common pool in a way that is neither equitable nor sustainable.
In a system without gazetted tariffs, general practitioners, specialists, and super-specialists are effectively free to set prices independently.
The result is not “choice” in any meaningful consumer sense; it is price dispersion that bears little relationship to what members can reasonably predict or budget for.
Faced with that reality, societies have two options. They can reimburse each provider’s invoice in full—creating unequal payouts for the same service and inviting rapid cost escalation—or they can reimburse a standard amount for that service so members are treated consistently. Most choose the second option, because it is the only one compatible with fairness and the long-term protection of the risk pool.
Take something as routine as a GP consultation. In the same town, for the same type of visit, one GP may charge US$20, another US$30, another US$40, and in some cases US$50.
If a society, aiming to treat members consistently, sets its reimbursement tariff at US$25, the math is straightforward: GP charges US$20: Society pays US$20 (no shortfall, assuming cover up to US$25). GP charges US$30: Society pays US$25; members pay US$5.
GP charges US$40: Society pays US$25; members pay US$15. GP charges US$50: Society pays US$25; members pay US$25.
Critics sometimes respond: “Then just pay what the doctor charges.” But that approach would mean two members receiving the same GP consultation could be reimbursed at radically different levels—simply because one visited a US$50 practice and another visited a US$20 one.
It would also reward higher pricing, normalize fee inflation, and strain the pooled fund that everyone contributes to.
Worse, it could push behavior in the wrong direction, nudging members toward the most expensive practitioners because price is mistakenly read as proof of quality.
If policymakers genuinely want to reduce shortfalls, the most effective interventions sit upstream—at the point where prices are set and communicated. That means confronting the absence of uniform provider tariffs and the information imbalance that leaves members exposed at the point of care.
The wider financing picture reinforces the point. Public health funding has repeatedly been flagged as below the 15% Abuja Declaration benchmark in recent years (for example, Community Working Group on Health commentary in 2025), which increases reliance on private providers and medical aids.
When public funding is constrained and insurance coverage is low, the case for a credible tariff framework becomes even stronger: it is one of the few tools that can reduce point-of-care price volatility without undermining the risk pool.
A practical reform agenda could include: Gazetted reference tariffs by discipline and procedure, updated periodically, to narrow extreme price variation.
Contracting frameworks that encourage providers and societies to agree on rates in exchange for predictable volumes and prompt payment.
Mandatory fee disclosure (before non-emergency services) so members can make informed choices and anticipate any copayment.
Clear benefit communication from societies—what is covered, up to what amount, and under what conditions—so expectations match reality.
None of this absolves medical aid societies from the need to run tight, transparent operations. But it does mean we should stop using shortfalls as a lazy proxy for prudential weakness.
In a market where provider fees are unconstrained and inconsistent, a society that pays consistently will always be accused of “not paying enough.”
The honest debate Zimbabwe needs is not whether schemes should abandon uniform reimbursement, but whether our health financing system can continue without credible, predictable pricing rules for the services members depend on.