Zambia’s health insurance dispute leaves patients stranded

On a bright Monday morning, Innocent Mwape walked into a private pharmacy along Lusaka’s Cairo Road and handed over a prescription for his life-critical diabetes medication. Mwape, 60, a retiree living with type 2 diabetes, already felt exhausted. Every step towards the next approved facility was more difficult for him, as his body was slowly showing signs of wear and tear. 

The pharmacist, however, told him that they no longer process NHIMA claims. Their suppliers won’t give them more stock until they pay the old bills, and they haven’t been paid in months, the pharmacist said. Yet for Mwape, buying the medicine himself is simply not an option. “I cannot afford to ‘buy now and claim later’. If the pharmacy says no to my local health insurance, it’s a ‘no’ to my health,” he says.

Concerns rising over a growing fallout

Mwape’s experience reflects a growing dispute between Zambia’s National Health Insurance Management Authority (NHIMA) and private healthcare providers, leaving ordinary patients caught in the middle with unfilled prescriptions and rising out-of-pocket costs.

Established under the National Health Insurance Act in 2018, NHIMA was created to implement and manage Zambia’s National Health Insurance Scheme (NHIS), with the goal of expanding access to quality, insured healthcare for all Zambians. But the authority has faced mounting challenges – including medical supply shortages, fraud, overbilling and inadequate regulation – that threaten its ability to deliver on that promise. 

“Due to an unsustainable settlement of claims for services provided to supported clients, we are cancelling our contract with the authority and intend to stop treating NHIMA patients,” Carepeak Specialist Clinic recently announced.

The Lusaka-based clinic is among several private facilities accredited by NHIMA that have been affected by the dispute, leaving many patients searching for alternative providers or having to pay for treatment themselves.

Concern over the growing fallout has prompted reactions from civil society organisations. “We are deeply concerned by the unfolding crisis surrounding NHIMA. Across the country, health centres are terminating their contracts with NHIMA due to persistent non-payment by the government,” says Solomon Ngoma, Executive Director of the Acton Institute for Policy Analysis Centre.

According to Ngoma, the dispute threatens to destabilise the healthcare system and jeopardise access to essential medical services for thousands of Zambians who depend on the national insurance scheme. Despite being established to ensure equitable access to healthcare, he argues that NHIMA’s failure to meet its financial obligations has left hospitals and clinics struggling to continue operating under the scheme. “Swift and decisive action is required to safeguard the lives of Zambians and preserve the integrity of the healthcare system,” he says. 

NHIMA, however, insists that members continue to have access to healthcare services despite Carepeak’s decision to withdraw. Head of Public Relations King Syacika said that while the authority respects the operational decisions of individual healthcare providers, claims circulating on social media that private facilities are withdrawing because of widespread non-payment are misleading.

“We wish to assure our members and the nation that the withdrawal of one private healthcare facility should not be used to undermine the NHIMA mission of ensuring access to affordable and quality healthcare services for all Zambians,” Syacika said.

For patients like Innocent Mwape, however, the dispute extends far beyond the exchange of statements between healthcare providers and the national insurer. For them, sooner or later it might be a matter of life and death.

Derrick Silimina is a freelance journalist based in Lusaka, Zambia. He focuses on Zambian agriculture and sustainability issues.
derricksilimina@gmail.com