🇿🇲 INSIGHT | NHIMA is Running Out of Money. Who Should Pay More?
Health Minister Roma Chilengi says NHIMA is financially unsustainable in its current form and Government will not allow the scheme to collapse. Speaking on ZNBC’s Sunday Interview, Chilengi said NHIMA “cannot continue offering health services that it cannot afford to pay for,” pointing to low contributions, high utilisation and an ambitious benefits package. The consequences are already visible, with some private health facilities withdrawing services over unpaid claims. Chilengi says Government is considering increased financing, improved revenue collection and a review of benefits, while studying systems in Ghana, Rwanda and Kenya.
So what are Zambians currently paying? NHIMA’s own contribution policy is clear: “Formal sector – 1% of your declared income from the employee and 1% employer contribution from the basic salary of the employee.” For informal-sector members, premiums are determined through NHIMA’s income-assessment system. Membership is compulsory for Zambians and established residents above 18 who earn an income, while senior citizens aged 65 and above and qualifying poor and vulnerable people can be registered without making the ordinary contribution. A principal member can register a spouse and five dependants below 18. In return, the scheme covers services ranging from medical care and surgery to maternity, medicines, laboratory and radiology investigations, eye and oral health, physiotherapy, mental health and selected cancer services.
The warning about sustainability did not begin with Chilengi. An actuarial review published by NHIMA examined the existing 2 percent combined formal-sector contribution and concluded the scheme would require progressively higher contribution rates to meet expenditure. Its model estimated a required rate of 2.77 percent in 2026, rising to 3.56 percent by 2032, if the underlying assumptions held. Parliament has seen the consequences of the imbalance too. Its Committee on Health reported claims loss ratios of 143 percent in 2023 and 135 percent in 2024, with unpaid claims exceeding K508 million in 2023 and K453 million in 2024.
In simple language, NHIMA has been promising and consuming more healthcare than its present financing structure can comfortably support.
The problem becomes harder when Zambia’s social obligations are added. Parliament was told claims generated by exempted beneficiaries had exceeded K850 million since the scheme began. Protecting elderly, poor and vulnerable people is precisely what a social health system should do, but exemption from contributions does not make their treatment free. The hospital still needs medicines. The laboratory still needs reagents. Doctors and nurses still need to be paid. If the patient does not finance the insurance premium, Government must adequately finance the exemption.
Free healthcare does not mean healthcare without a cost. It means somebody else carries the cost.
This is where we believe Government should widen the discussion before simply increasing everybody’s contribution. One option worth examining is a basic universal NHIMA package, protecting essential healthcare for every member, alongside optional higher contribution packages for people who want additional benefits. A member could, for example, choose a higher premium for enhanced optical, dental, private-room or other non-essential benefits while core treatment remains protected for everyone.
But the line must be drawn carefully. Zambia should not create a system where a K250 contributor can receive life-saving cancer treatment while a K70 contributor cannot. Illness does not check a payslip before it arrives. Social insurance works because risk is shared.
Before asking workers and employers for more money, Government must also examine where the existing money goes. A recent peer-reviewed study on Zambia’s NHIMA found stakeholders raising concerns about over-utilisation, provider-induced demand and fraud. One participant involved in the system said: “The scheme didn’t react fast enough to put safety measures against over utilization, provider induced demand, fraud.” Another described the underlying problem more starkly: “Now its expenses have superseded the collections in premiums.”
Those concerns should matter when Government reviews the scheme. Increasing contributions without tightening claims verification, controlling unnecessary procedures, collecting outstanding premiums and improving provider management could simply pour more money into the same weaknesses.
Chilengi’s approach at the Ministry of Health suggests he is prepared to restructure institutions rather than preserve systems which are failing. Only days ago, he announced the separation of all staff at ZAMMSA following a forensic audit which, according to him, found “serious and widespread weaknesses” across procurement, warehousing and distribution, including inflated procurements, unaccounted stock and missing records. He described the problems as “systemic failures at
level of the processes.”
NHIMA presents a different problem and should not be equated with ZAMMSA, but the principle of reform is similar: first establish what is broken, identify where money is being lost, determine what services Zambia can sustainably finance, and then decide what citizens and Government should contribute.
The real NHIMA debate is therefore bigger than whether the monthly contribution should rise from 1 percent to some higher figure. Zambia must decide what healthcare every citizen should be guaranteed, what it actually costs and who pays when contributions fall short. Government may have to put in more money.
Workers and employers may eventually have to contribute more. Optional packages could help finance additional benefits, while fraud, waste and weak collection must be dealt with before patients carry a larger burden. Chilengi is right about one fundamental point: NHIMA cannot indefinitely promise healthcare it cannot afford. But the answer cannot be to make adequate healthcare available only to people who can afford the highest package.
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The Minister has not applied himself in the matter nor in his statement.
State funded medical insurance is not just a Zambian problem but an issue that plagues even the most developed of states. Some Insurance products are infact what in business termed as “Loss leaders” like Motor Insurance. Yet insurance companies by law are compelled to provide the products.
Medical Aid and NHS medical insurance schemes provided for in the US and UK respectly. They are publicly administered schemes that in the US the Republicans have sought to scrap as they add to the National Debt. The number of aging population that dip into the medical scheme out number those that contribute. In Zambia the issue is we have a youthful population and that arguement should not stand.
This is why I say the Minister and those involved have not applied themselves to the issue by their wholesale statement on the issue. To me as a PhD the Minister is thrown a challenge to think creatively and criticaly on the issue before issuing such a statement as he did on the reinstatement of people he fired two days ago. He should taken time to think deeply on the matter than make contradictory statement that make us question his decision making ability.
This man comes from State House as an Advisor to the President. What kind of advice was the man rendering to the head of State for such decisions to be made at Ministry level?
This doesnt stop at the Minister alone. He has technocrats that surround him at the ministry. Where are they? Maybe the shake up needs to start there. If this is reflective of their abilities. This is why expertiates seem justified in the Private sector and we cry about the growing Forex flight out of the state. What is so special about these expertiates? Zambian have the qualifications but fail to apply themselves at the job as we see. How does the Growth agenda then work if those said technocrates dont add value? Pls view my comments as a challenge.