Ministry of Health, Community Health Sciences Unit (CHSU), Private Bag 65, Area 3, Lilongwe, Malawi.
Department of Pharmacy and Pharmaceutical Sciences, Faculty of Medicine and Health Sciences, University of Zimbabwe, P. O. Box A178, Avondale, Harare, Zimbabwe.
Int J Equity Health. 2022 Mar 27;21(1):42. doi: 10.1186/s12939-022-01646-z.
Implementation of health financing reforms for Universal Health Coverage (UHC) is inherently political. Despite the political determinants of UHC, health financing reform in Zimbabwe is often portrayed as a technical exercise with a familiar path of a thorough diagnosis of technical gaps followed by detailed prescriptions of reform priorities. In this study, we sought to understand the interaction between political and economic aspects of health financing reforms since the country got its independence in 1980.
We conducted a scoping review of health financing reforms in Zimbabwe and reviewed 84 relevant sources of information. We then conducted a thematic analysis using an adapted Fox and Reich's framework of ideas and ideologies, interests and institutions.
We found that ideas, institutions and interests significantly influence health financing reforms in Zimbabwe with implications on health system performance. Reform priorities of the 1980s were influenced by socialist ideologies with an interest to address pervasive health inequities inherited from the colonial racial system. The progress in equity realized in the 1980s was severely disrupted from the 1990s partly due to neo-liberal ideologies which steered interests towards market-oriented reforms. The period from the 2000s is characterized by increasing donor influence on health financing and a cumulative socio-economic collapse that resulted in a sharp and protracted decline in health spending and widening of health inequities.
Health financing reform process in Zimbabwe is heavily influenced by political economy characteristics which favor certain financing arrangements over others with profound implications on health system performance. We concluded that the political economy factors that slow down UHC reforms are not rooted in the ambiguities of ideas on what needs to be done. Instead, the missing link is how to move from intention to action by aligning espoused ideas with interests and institutions which is an inherently political and redistributive process. International and domestic actors involved in UHC in Zimbabwe need to explicitly consider the politics of health financing reforms to improve the implementation feasibility of desired reforms.
实现全民健康覆盖（UHC）的卫生筹资改革本质上是政治性的。尽管全民健康覆盖的决定因素具有政治性，但津巴布韦的卫生筹资改革通常被描绘为一项技术性工作，其熟悉的路径是对技术差距进行彻底诊断，然后详细规定改革重点。在这项研究中，我们试图了解自 1980 年该国独立以来，卫生筹资改革中政治和经济方面的相互作用。
我们对津巴布韦的卫生筹资改革进行了范围界定审查，并审查了 84 个相关信息来源。然后，我们使用 Fox 和 Reich 的思想和意识形态、利益和机构框架的改编版进行了主题分析。
我们发现，思想、制度和利益极大地影响了津巴布韦的卫生筹资改革，对卫生系统绩效产生了影响。20 世纪 80 年代的改革重点受到社会主义思想的影响，这些思想的兴趣在于解决殖民种族制度遗留下来的普遍健康不平等问题。20 世纪 80 年代实现的公平进展在 20 世纪 90 年代受到严重干扰，部分原因是新自由主义思想使利益偏向面向市场的改革。21 世纪以来的特点是捐助者对卫生筹资的影响越来越大，以及社会经济的累积崩溃，导致卫生支出急剧下降和健康不平等扩大。
津巴布韦的卫生筹资改革进程受到政治经济特征的严重影响，这些特征有利于某些筹资安排而不利于其他安排，对卫生系统绩效产生深远影响。我们的结论是，阻碍全民健康覆盖改革的政治经济因素并非源于对需要做什么的思想模糊性。相反，关键在于如何通过使所拥护的思想与利益和机构保持一致来将意图转化为行动，这是一个固有的政治性和再分配过程。参与津巴布韦全民健康覆盖的国际和国内行为体需要明确考虑卫生筹资改革的政治问题，以提高所需改革的实施可行性。
