13. Man An Evaluation Of Business Models In The Private Healthcare Services Sector In Zimbabwe Reviewed 1

IMPACT: International Journal of Research in
Business Management (IMPACT: IJRBM)
ISSN(P): 2347-4572; ISSN(E): 2321-886X
Vol. 5, Issue 5, May 2017, 117-136
© Impact Journals

AN EVALUATION OF BUSINESS MODELS IN THE PRIVATE HEALTHCARE SERVICES
SECTOR IN ZIMBABWE: A CASE STUDY OF THREE HEALTHCARE

COMPANIES IN HARARE

MASANGA, G. G, MUNYORO, G & MUGWAGWA, P. F

Graduate Business School, School of Entrepreneurship and Business Sciences,

Chinhoyi University of Technology, Chinhoyi, Zimbabwe

ABSTRACT

Business models the in healthcare industry, internationally, have been found to contribute to high cost of
healthcare services and poor service delivery. This research aimed at evaluating the business models being used in the
private healthcare sector in Zimbabwe, with a view to improve value for the stakeholders. The research philosophy was
phenomenological and took a multiple case study design. Three prominent healthcare companies were selected for
the study, and a purposive sampling method was used to select the respondents for the study. The study established that
the business models in use in the private healthcare services sector in Zimbabwe are following the STOF model, although
the model is not yet clearly defined. The costs in the private healthcare system are significantly influenced by private
insurance companies. The study also established that, the healthcare industry is too fragmented and therefore unable to
influence policy or reform. The research recommended that Government establishes medical centres of excellence that
could serve the community at low cost with a provision for flying in specialists to serve at the centre when required.
Government is also urged to relax regulations regarding advertising of medical services to promote healthcare competition
and improve on service quality.

KEYWORDS: Healthcare Business Models, Cost of Healthcare Services, Quality of Healthcare, Medical Service
Regulations

INTRODUCTION

The Zimbabwe health system has been in decline for more than a decade and the result has been a decrease in
coverage of most basic services (Madzorera, in Ministry of Health and Child Welfare, 2010). The per capita expenditure
has remained below the World Health Organization threshold of USD 34.00 (WHO, 2010b). According to the Ministry of
Health, Zimbabwe per capita was USD19.40 in 2014 USD 16.50 in 2015 (Ministry of Health and Child Care, 2016). In an
effort to reverse the situation, the ministry of health devised the Zimbabwe Health Sector Investment plan (2010-2012) to
mobilise resources to revitalise the health system. Private facilities were able to step in and provide service, however as the
Zimbabwe Government contribution decreased, external funders and households have covered the financial burden, and
households expenditure has increased from 23% to 62%.(Osika, Altiman et al, 2010). Furthermore, the contributions of
households are made through private health insurance companies, whose cost may be negatively affecting households.
With regard to healthcare costs, there is a growing consensus that the twentieth-century model of healthcare is no longer
sustainable (Grossman, 2007).

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Studies carried out on business models in countries such as Belgium, Netherlands, Sweden and Norway show that
business models have an effect on costs and quality of healthcare outcomes. A business model describes the value logic of
an organization in terms of creating and capturing customer value and the elements of a business model result in a cost
structure (Teece, 2010; Osterwalder and Pineur, 2010) Currently, Zimbabwe is sending patients to India, South Africa
among other countries, for medical treatment, even though some of the medical services are found within Zimbabwe,
implying that costs, and in some cases healthcare outcomes are better elsewhere than they are in Zimbabwe.

The research objective of this study was to determine the business models in the private healthcare sector in
Zimbabwe. There is a growing consensus that the twentieth century model of health care is no longer sustainable
(Grossman, 2007). What business models exist in the private healthcare in Zimbabwe? Are these models placing a cost
burden on households and the health services sector as has been revealed in literature and yet countries such as India,
Thailand and Singapore amongst others are able to offer health services at competitive rates (National Centre for Policy
Report, 2007). It is important to understand how resources are being employed in the private health sector, now that it is
serving 70% of the country’s population as noted by the IFC (2007). Knowledge of Zimbabwe's private sector healthcare
business models might help to find solutions to the medical tourism market which has been created out of Zimbabwean
patients. Patients are being exported by insurance companies to other countries for treatment, even though some of
the services are available in the country. It is therefore important to evaluate the effectiveness of existing healthcare
business models, and their ability to create affordable value for all stakeholders with a view to improve these models for
competitive advantage.

LITERATURE REVIEW
What is a Business Model?

Every company has a business model, even though in some instances the model is explicitly articulated, while in
some instances the model may not be clearly articulated (Teece, 2010; Chesborough, 2006). Amit & Zott (2010) define a
business model as the design of transaction content, structure and governance of a business so as to create value through
the exploitation of business opportunities. In their view, value creation should be conducted within a business model.
Whilst this definition acknowledges the interaction of activities to construct a business model, their emphasis is on how
such interactions are meant to create profits for the business. The Amit et al (2010) definition is generic such that it has no
particular emphasis to any particular industry's business model. It can actually define a company whose aim is to create
profits or can refer to how an entire industry creates profits. This can lead to the conclusion that a business model can be
defined as any business whose main goal is to create value.

In their book, Osterwalder and Pignew (2010) present a business model canvass for a shared view for describing,
assessing and changing business models consisting of nine blocks. These blocks present a wider explanation of
the elements and activities in a business model. Earlier, Chesbrough and Rosenbloom (2002) had defined a business model
as a blueprint that describes how a network of organizations cooperate in creating and capturing value from new,
innovative services or products. They went further to interpret the business model as the heuristic logic that connects
technical potential with the realization of economic value. In this case they confine the definition of a business model to
the capturing of value from a network of new innovations. This definition has a bias towards technological innovations and
how they create value for a network. The definition also does not include the creation of value from existing services and

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products thereby implying that economic value can only be created from new services and products. However, the above
authors agree that a business model's objective is to create value. Similarly, Haaker et al (2004) defined a business model
as a model of profits, and the concept of generating these profits is considered to be the business model in order to create
customer value. Furthermore, in a later definition, Bowman, De Vos and Haaker etal (2008) focused on business models
for service offerings which require cross company or multi- actor collaboration. They argue that a business model is
considered a networked enterprise with a collaborative effort of multiple companies to offer a joint proposition to
consumers. From their perspective a business model can be seen as a blueprint for interrelated components; service
offering, technical architecture, organizational and financial arrangements (STOF). They believe that a business model
describes how, in a chain or network of customers, network value is created. Their definition of a business model has a
particular bias towards companies in the service industry. In addition, their definition takes care to include what they view
as the four main components of a business model which are service offering, technical architecture, organizational and
financial arrangement. There is equal emphasis on customer value and network value or profits. This study believes that
this definition is the most appropriate to use in analyzing the business models in the healthcare sector since the health
sector is also a service industry. Consequently, in this study, a business model is defined as a blueprint or framework that
creates or adds value, and involves a complex interaction of activities both inside and outside the firm to create value for
all stakeholders, and this includes value creation (the resultant benefit of business setup) and networking (connection of a
complex system).

The Main Components of Bowman et al (2008) Business Model

Bowman et al (2008) focused on business models for service offerings, which require cross company or
multi- actor collaboration. A business model can be considered a networked enterprise, a collaborative effort of multiple
companies to offer a joint proposition to consumers (Haaker et al 2006). From their perspective a business model can be
seen as a blueprint for interrelated components; service offering, technical architecture, organizational and financial
arrangements (STOF). It describes how in a chain or network customer value, net-work value is created. From the earlier
definition of the business model and its underlying key features it can be noted that there are similarities between a general
business model and the STOF model. In the model technology describes a technical functionality required to realize
the service and moves in line with the formulation of the competitive strategy by which the innovating firm will gain and
hold an advantage over rivals that the business model outlines. The revenue generation mechanisms for the firm, and
estimation of the cost structure and profit potential of producing the offering, given the value proposition and value-chain
structure chosen, is one of the characteristic of a general business model. This can be associated with the finance domain in
the STOF model. The common term of revenue generation as noted, whether it is a general business model or it is a STOF
model, its ultimate goal is making a profit. The components of STOF model are explained as follows:

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MARKET OPPORTUNITIES

E.g. Improvement of Communication in the Healthcare

TECHNICAL

DEVELOPMENTS

!r

Figure 1: STOF Model Adapted from Bouwman et al, 2008

According to the Smart Services CRC (2011), the STOF model consists of the following

domains

(Bouwman, Faber, Flaaker, Kijl, & De Reuver, 2008):

• Sen’ice domain: The central issue in designing a service is ‘value a provider intends to deliver a certain value
proposition and customers or end-users expect and perceive a certain customer value. This is addressed by four
inter-related concepts: intended and delivered value on the part of the provider, and expected and perceived value
on the part of the customer or end-user.

• Technology domain: For mobile services, technological considerations relate to technological architecture,
technological functionality, backbone infrastructure, access networks, service platforms, devices, applications,
and data.

• Organization domain: The organizational issues revolve around the resources and capabilities, mainly related to
technology, marketing and finance that have to be made available to enable the service. For mobile sendees, this
often requires organizations to collaborate in a business network.

• Finance domain: Financial resources are one of the most important resources to be required. Finance also
defines the bottom line of most of the sendees to be designed. With regard to financial arrangements, there are
two main issues: investment decisions and revenue models.

All the components of the STOF model communicate the value proposition that is, the value created for customers by
the product or service on offer, which is a fundamental term in business models analysis. This model can be appropriate for
the health sector business since the four domains exist in the healthcare business.

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The Chesbrough and Rosenbloom Model

The Chesbrough and Rosenbloom model (2002) proposes six functions which provide a coherent framework that
takes technological characteristics and potentials as inputs, and converts them through customers and markets into
economic outputs. The business model is thus conceived as a focusing device that mediates between technology
development and economic value creation. A business model is said to integrate a variety of academic and functional
disciplines. The six functions referred to in the Chesbrough and Rosenbloom business model are as follows:

Business

model

market

value

proposition
value chain;
costand profit.

Measured m

Figure 2: Functions Model Adapted from Chesbrough and Rosenbloom (2002)

The six functions involve identifying a market segment, articulating the value proposition, defining the structure
of the value chain, estimating the cost structure and profit potential of producing the offering, describing the position of
the firm within the value network linking suppliers and customers and formulating the competitive strategy by which the
innovating firm will gain and hold advantage over rivals (Chesbrough and Rosenbloom 2002).

The above business models emanate from theories of industrial business strategy.

Theories of Business Strategy

The Industrial Organisation theory (IO) is relevant to this study, in that it covers environmental analysis, an
analysis considered critical in any business strategy formulation. The IO theory originates from the works of Mason (1953)
and Bain (1968) amongst others who argued that industry structure was the sole determinant of industry behaviour and
performance. Porter (1976, 1977) advanced the IO concepts at business level strategy to assess the attractiveness of an
industry. He argued that industry structure determines the behaviour or conduct of firms, whose joint conduct then
determines the collective performance of the firms in the marketplace (Mason, 1953). The framework used to support the
IO theory in analysis of industries and firms was the Five Forces Framework (Porter, 2008). He further argued that if this
framework was properly done, then the firm could earn above average returns. A critical analysis of the IO theory shows
that there is a relationship between this theory and the business model definition by Amit & Zott (2001) where they define
a business model as the design of transaction content, structure and governance. One of its major propositions is that
the structure of the industry determines the behaviour and conduct of the firms in that industry, which in turn influences
the performance of the firms. There are therefore some similarities in the business model approach to IO theoretical
frameworks, that is, the 5 Forces Framework and the Value Chain Analysis (Porter, 1985).

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All are a breakdown of the firm’s internal and external activities to follow, how value is created through to the end
of the chain. Infrastructural interrelations (firm infrastructure and human resources management) in value chain analysis
are covered by the organisational arrangements; technological interrelations (Technology developments) are represented by
technical architecture in business model definition by Bowman et al (2008) in the STOF model. Marketing, sales and
services in the Value Chain Analysis are what Bowman et al (2008) refers to as service offering. This approach to strategy
formulation was a great acknowledgement of the power of the external environment of the firm at the same time ignoring
any internal capabilities that the firm may have which can influence its performance.

The industry structure approach to strategy making is contrasted with the Resource Based View (RBV) theory of
competitive advantage (Barney, 1991). The RBV is an approach to achieving competitive advantage that emerged in 1980s
and 1990s (Wernerfelt, 1984; Grant, 1991) and it aspires to explain the internal resources of a firm for sustained
competitive advantage. The RBV’s central proposition is that if a firm is to achieve a state of sustained competitive
advantage it must acquire and control valuable, rare, inimitable, and non-substitutable (VRIN) resources and capabilities,
as well as have the organization in place that can absorb and apply them (Barney, 2001; Carter, Cleg and Korberger,
2009.). The supporters of this view argue that organizations should look inside the company to find the sources of
competitive advantage instead of looking at the competitive environment (Grant, 2010). In the researcher’s view, a
business model can be seen as a modified resource based view strategy to creating competitive advantage.
With the business model approach, the idea is to organize the resources of a firm in a manner that create capabilities in
the organization that no one else has or that are difficult to emulate since the central premise of the Resource-Based View
is that firms compete on the basis of their resources and capabilities (Peteraf and Bergen, 2003).

According to Grant (2010), the RBV uses two assumptions in analysing the sources of competitive advantage.
First, this model assumes that firms within an industry may be varied with respect to the bundle of resources that they
control. Second, it assumes that resource heterogeneity may continue over time because the resources used to implement
firms’ strategies are not perfectly mobile across a firm that is some of the resources cannot be traded in factor markets and
are difficult to accumulate and imitate (Grant, 2010). Resource heterogeneity or uniqueness is considered a necessary
condition for a resource bundle to contribute to a competitive advantage.

However, the dynamic nature of today's business environment and the static nature of the RBV necessitated
the need to improve the RBV through the concept of dynamic capabilities. These two theories are relevant in this study as
the healthcare businesses depend on resources and the capabilities of their medical experts in a rapidly changing
environment. Dynamic capabilities, by contrast, refer to the capacity of an organization to purposefully create, extend, or
modify its resource base to cope with the rapidly changing environment (Helfat et al., 2007). The dynamic capabilities
concept was defined by Teece, Shuen and Pissano (1997) as the firm’s ability to integrate, build, and reconfigure internal
and external competences to address rapidly changing environments. The basic assumption of the dynamic capabilities
framework is that core competencies should be used to modify short-term competitive positions that can be used to build
longer-term competitive advantage. It thus provides a bridge between the economics-based strategy literature such as
the industrial organization theory and evolutionary approaches to organizations (Douma, 2013). This attempt at fusing
the static theory perspective that is embodied in the industrial organization theory, and the inside out approach of
the resource based view can be credited with the birth of the business model innovation approach to strategic management
(Helfat, 2007).

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The emphasis of this view is on ensuring that strategic management takes into account the rapidly changing
business environment in crafting, implementing and management of the business. It also places equal importance on
the internal and external environments of the firm and how both of these environments can be manipulated to create
capabilities for the firm to handle a changing environment in a manner that gives value to stakeholders (Teece, 2010).
The business model approach fully embraces the dynamic view of strategy by ensuring that the business model elements
are capable of adapting to changing environment (Douma, 2013). If a business model is to be analyzed in relation to
the dynamic view, it will imply that the service offering needs to be continuously reviewed in line with changing customer
preferences, whilst adopting the latest technology to facilitate the delivery of these service offerings. The organizational
arrangement also requires continuous improvement through business process reengineering exercises. The advent of
modern financial arrangement such as mobile money to compliment plastic money also needs to be incorporated into a
business model for the model to remain relevant to its stakeholders (Munyoro and Matinde, 2016).

In conclusion, it can be seen that the three theories above have a fundamental relationship with the two models
discussed above.

RESEARCH METHOD

This study used a phenomenological approach (Saunders et al 2009; Moustakas, 1994), because in the human
sphere, there is normally a need to gather deep information and perceptions through inductive, qualitative methods such as
interviews, discussions and participant observation, and representing it from the perspective of the research participant
(Measor, 1985). The use of phenomenological approach therefore helped to get a deeper understanding of the private
healthcare business models in Zimbabwe from the perspective of the healthcare service providers, the suppliers and
the customers (the patients). In order to understand the complex nature of the task at hand, a multiple case study of three
healthcare companies was employed in the research design (Saunders, 2003), and multiple methods such as interviews,
observations, questionnaires, focus groups and documentary analysis were used and this was aimed at analysing persons,
events, decisions, periods, projects, policies, institutions, or other systems that are studied holistically by one or more
methods. The population for this study was obtained from the three organization's registered centres, all from Harare as
well as from customers and medical vendors. Non probability sampling method called purposive sampling (Wegner, 1999)
was used to select the health care companies and stratified random sampling (Marshal etal, 2013) was used to select
internal personnel for interviews. The questions took the form of both multiple choice and open questions, allowing
respondents freedom to express their views concerning new methods of assessment (Cohen and Manion, 1994; Munyoro,
2014). The response was high, with 95 percent of the respondents returning their questionnaires. Questionnaires were used
as a means of collecting data, the reason being that they are reliable, unambiguous, uniformly workable, easy to administer,
cheap and fast (Cooper and Schindler, 2001; Altrichter et al, 2008). Furthermore, in addition to focus group and
observations questionnaires were used because they have fewer errors from research participants for the reason that their
involvement is voluntary and they are also engaged in their areas of interest, thus encouraging them to cooperate in
obtaining answers as close as possible to the truth (Cooper and Schindler, 2001; Cohen and Manion, 1994). As noted by
Munyoro (2014), Thorpe and Holt (2008), Fern (2001), and Fontana and Frey (1994),

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This method of using questionnaires is also well accepted and admired because it promotes the establishment of
trust and commitment, something that is regarded as a precondition in such types of studies because it enables the
researcher to examine the inner world of the respondents.

Qualitative Data Analysis (QDA) was used for data analysis as noted by Mack et al (2005) Munyoro (2014) and
Seidel (1998). In line with Seidel and Kelle (1995), the process of QDA involves coding and writing. In this case, themes
were identified through passages of text and labels were identified that indicated some thematic idea (Mack et al, 2005).
This labelling or coding of these themes enabled the quick retrieval of all the texts that were associated with a particular
thematic idea, and were examined and compared. The researchers divided the model into three parts, namely Noticing,
Collecting and Thinking about interesting things using Seidel’s 1998 model. These parts are interlinked and cyclical. As
suggested by Seidel, the researchers noticed interesting things in the data and assigned ‘codes’ to them, based on the topic
or theme as shown in the findings section, and these codes were in turn used to break the data into fragments (Saunders et
al, 2009). The codes were then used to act as sorting and collection devices. After that, the researchers wrote about the data
and the findings and this involved writing a summary of the data which also entailed some analytic ideas (Gibbs, 2002).

RESULTS AND DISCUSSIONS

This section gives a summary of the key findings and conclusions of the research study. The major research
findings are presented below:

Table 1: Demographics and Characteristics of Respondents N = 120

Male

53

44.3%

Female

67

55.7%

Age

Below 30

59

49.2%

30-40

31

26.2%

40-50

26

21.3%

Above 50

4

33%

Employment status customers

Self employed

12

10%

Formally employed

71

59.17%

Unemployed

20

16.67%

Student

16

13.33%

Other

4

0.833%

Marital status

Married

60

50%

Single

50

41.7%

Widowed

4

3.3%

Divorced

4

3.3%

Other

2

1.7%

Residential areas

High density

41

34.4%

Medium density

49

41%

Low density

22

18.33%

Plots and farms

1

0.833%

Other

7

5.83%

The table above shows the frequency of male 53(44.3%) and female 67(55.7), this gender distribution of the
respondents is acceptable and representative, since the Zimbabwe National Population Census Report (2012) shows the

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population gender distribution mix as 48% male and 52% female. Similarly, the largest number of the respondents who
participated in the survey was below the age of 30 years followed by those between 30 and 40 years.

These two age groups constitute the most economically active people in the country and can afford private
healthcare services for their families. This also makes a good target market for healthcare companies as the age population
distribution according to National Census Report (2012) indicates that 41%of the population is under the age of 15 years,
55% is between 15 and 64 years and the remaining 4%vis above 64 years. A large number of respondents 71(55%) were
formerly employed and a significant number 20(16.67%) were self-employed or were students 16(33.33%) whose medicals
bills are still being managed by their parents or guardians.

Table 2: Business Domains in Healthcare Organizations.

Business Component

Organization 1

Organization 2

Organization 3

1.1 Medical Services provided

57 registered centres
Hospitalisation services
And medical centres.
Optometry, Radiology,
Laboratory, Renal
services

Rehabilitation

Pharmacy services

General surgery

12 registered centres
Hospitalisation services for
medical & surgical
patients, ear, nose and
throat services,
rehabilitation services,
Accident emergency
services

Pharmacy services

6 registered centres
Emergency services
General practitioner
Walk-In services

Pharmacy services

1.2 Transport services

Ambulances

Nil

Nil

1.3 Specialist services

Urology

Gynaecology

Obstetrics

Ophthalmology

Nephrology

Ear, Nose and Throat
(ENT)

Dialysis

Chemotherapy

Post Graduate Nursing
School.

Coffee Shop

2. 1 Technology available (ICT)

Internet

Computers

Website

Point of sale system

Internet

Computers

Website

Mobile and line phones

Internet

Computers

Website

Mobile phones

2.2 Medical equipment

Optometry

manufacturing

equipment

Dental services
equipment

Radiology and clinical
laboratory equipment
Physiotherapy
equipment

Dialysis equipment
Specialist equipment for

Gynaecology &

Obstetrics

Surgery

Ophthalmology

Ear, Nose and Throat
(ENT)

Chemotherapy equipment
Dialysis equipment

Ear, nose and throat
equipment

Vaccination
laboratory equipment
X-ray

Ultra sound scan
services

Body mass index
machine

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Table 2:

Contd.,

3 Financial Activities

Group Finance, Risk and
Audit at head office

60 days creditors and
debtors policy.

Accepts medical aid
schemes

Investment Policy

Accounts Department
exists

60 days creditors and
debtors policy.

Accepts medical aid
schemes

Investment Policy

Accounts Department

Cash settlement plus 60
days creditors and
debtors’ policy.

Accepts medical aid
schemes

Investment policy

4 Organizational
structures

A Corporate medical
services Organization

A medical services
company

A Medical Centre
company

Operates a hybrid of
subsidiary medical centre
units in various cities
comprising of

Emergency, Primary care
and the family doctor.

Each SBU is headed by a
General manager, who
reports to the group
operations manager. The
group is a market leader
in medical services.

Runs a multifaceted
hospital, and, an ear,
nose and throat clinic, a
Rehabilitation nursing
home and a post graduate
nursing school.

The organization adheres
to ISO 9001 quality
standard.

The organization is run
by a Managing Director.

It is an emergency and
medical walk in facility.
The facility has
emergency room setting
where a doctor does not
have a consulting room
but will attend to walk in
patients allocated to
emergency rooms.

The founder is the Chief
Executive Officer

Table 2 above shows three medical business organizations operating in Zimbabwe and how the organizations
business components are structured in each healthcare business. Teece (2010) indicated that every company has a business
model, the three healthcare companies’ exhibit different forms of business models. In this study the different business
components have been grouped according to their business scope, services offered, technology in application, financial
services and management structure (Bowman et al, 2008). While organization 1 has a nationwide spread the other two
organizations are more limited. From the earlier definitions of the business model and its underlying key features, it can be
noted that there are similarities in the general business model and the STOF model. Amit and Zott (2010) defined a
business model as the design of transaction content, structure and governance so as to create value through the exploitation
of business opportunities. The organizations above show networked enterprises with collaborative efforts to give focussed
business propositions to customers (Bowman et al, 2008).

Zimbabwe’s Healthcare Organizations Compliance with Bowman et al (2008) Business Model
The Service Component in Healthcare Companies

The study established that, the STOF model is the closest business model in use in the sector, but it is not yet fully
developed. Having established that the STOF model is the model in use, the variations in the business models come in how
each company is structured and manages each component. As noted by Bowman et al (2008) the service component
describes the services offered by the healthcare companies and their target market. Organization 1 value proposition
appears to provide all types of medical services throughout the country, serving several customer segments (Osterwalder
and Pigneur, 2010), from general practitioner to specialist services and from medical centres to General Hospitals as well
as procurement of medicines. However, diversification of this magnitude is risky in that value propositions may not be

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successfully offered. Porter (1996) argues that diversification inevitably adds costs and is risky unless managed carefully.
If key resources are thinly spread this may have negative cost repercussions on the customer. The other two healthcare
service companies have more limited service models, being more compact with organization 2 stating that “ it pledges to
provide quality products and services to its patience, doctors, employees and other stake holders and also to maintain a
quality management system based on ISO 9000”. Organization 3 is much smaller and offers emergency walk in services
including accidents, pharmacy, Laboratory, X-ray and ultra-sound and ambulances services. This organization is situated
on one site and is not affiliated to any quality standard. According to the Zimbabwe Health Professions Act (Chapter
27:19) a licence to trade in any healthcare service is awarded to a practitioner and not to a corporate legal entity or a non-
medical practitioner. This has serious implications to governance, control and financing. The study established that in
Zimbabwe prices for healthcare are dictated by the Association of Healthcare Funders of Zimbabwe (AHFoZ), an
institution that represents the interests of medical insurers. This association establishes reference tariffs of fee structures
and is responsible for accreditation and registration of healthcare providers ( www.ahfoz.org , 2016). This forces service
providers to design their service models around the dictation of medical insurers.

Technology Component in Health Care Companies in Zimbabwe

The STOF model sees technology as playing a central role as an enabler of customer value from a customer
perspective (Smart Services CRC, 2011). This study established that investment in technological infrastructure and service
platforms is very weak in the private sector. There is low utilisation of technology such as ICT systems, and there is also a
reluctance to admit operational competency gaps by employees. As an example low utilisation of the Management
Information System by senior managers can be seen from the insistence by some senior managers to responding to emails
through printing the emails and manually writing the responses on hard copies and using their personal assistants to read
and respond to their emails. Mobile technology and social media are the most underutilised in the industry. Healthcare
companies are not working together to invest in technology, and as a result of this poor investment in technology, the
information repository in the sector lacks information and depth and is mostly inaccessible and disjointed. Remlex (2007)
argues that ICT plays a major role in driving healthcare costs down. However, where senior people in the organization lack
the skills to use the computers and internet for healthcare services, as noted by Achampong (2012) use of diagnostic
information systems will hardly be taken advantage of thereby missing the opportunity to reduce costs.

The Governance Component in Healthcare Companies

Bouwman et al (2008) consider issues of resources and capabilities in their organizational domain, while Haaker
et al (2004) define organizational domain, as the structure of the multi-actor value network required to create and distribute
the services and to describe a firm’s position. In this study the structure of the organizations and their governance systems
were considered including the availability of quality management systems. The study established that 2 of the
organizations have boards of directors who oversee an operating day to day management, while one organization is a sole
trader company. Organization 1 is a fully fledged corporate company with business units run by a General Manager
reporting to the Group Operations Manager at head office. The organization staff members have developed a culture where
they consider themselves as the most important stake holders ahead of the patients. Private healthcare companies do not
place importance on quality of outcomes arising from their services due to the fixed pricing model used in the industry
(AHFoZ, 2016) which explains why 2 of the 3 cases were not affiliated to any quality body. Organization 2 is run by an

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Executive director, and currently enjoys an excellent brand reputation. It is affiliated to a quality management system and
is ISO 9001 certified. The organization culture encourages accountability. Organization 3 is owned and run by one
shareholder. The founder of the healthcare company is the chief executive officer of the company and a few senior
managers report directly to him. The respondents reported that the attitude of the medical staff is polite and helpful;
however administrative staff attitudes are distant and cold. There is no service promise on display in the waiting area.

As can be seen from the above table, the configuration of resources of each private healthcare company are directly related
to the availability of resources and by the nature of services offered. Key resources are the assets required to offer and
deliver the various service elements (Osterwalder and Pigneur, 2010).

Financial Management in Healthcare Companies

According to Haaker et al (2004), the financial domain is “a description of the way a value network intends to
generate revenues from a particular service and of the way risk; investments and revenues are divided among the various
actors within the network.” The three healthcare companies assessed acknowledged the existence of accounting
departments within their organizations. However the three organizations lamented the lack of flexibility as the rates and
charging structure is controlled by the association of healthcare insurance companies (AHFoZ, 2016). Respondents from
the healthcare companies indicated that most of their clients are members or children of insurance based medical aid
societies belonging to AHFoZ. The study established that the financial management in healthcare companies is negatively
affected by non- payment for services by medical insurance companies. This causes a chain reaction in the healthcare value
chain as the healthcare services providers fail to pay their suppliers in time. Inevitably this has repercussions on costs as
only those organizations with economies of scale can benefit from such an environment. However even large organization
cannot survive if such practices are sustained. This has serious operational implications to healthcare industry as it limits
any developments in technology based innovations or business model innovations as suggested by WHO (2008).

Government Regulations and Impact on Healthcare Companies in Zimbabwe

In Zimbabwe according to the Health Professions Act (Chapter 27:19), a license to trade in any healthcare service
is awarded through a practitioner not to a corporate legal entity or non- medical practitioner. This creates a heavy burden
on the models that come into the market since they have to comply with legislation. In view of the licensing structure,
ultimately each graduating medical doctor from the university eventually drifts to opening their own medical practice.
While this is commendable it has the undesired effect of fragmenting the medical industry into thousands of small
businesses run by technically trained people but lacking in management competence. For example the curriculum run by
the University of Zimbabwe is designed for a professional medical person (University of Zimbabwe Curriculum, 2014).
Furthermore, such fragmentation makes it difficult for the healthcare industry to unite and push for meaningful reforms for
their industry, and the incumbents struggle to innovate their businesses, and this has the tendency to increase cost and fee
structures, due to diseconomies of scale (Parma et al, 2014; Koen et al, 201 1).

Determinants of Cost Structure in Health Care Organizations in Zimbabwe

Prices for healthcare services in Zimbabwe are dictated to service providers by AfHoZ, an institution that
represents the interests of medical insurers in Zimbabwe. Service providers are therefore forced to create their business
models around the dictated prices due to the fragmented nature of the healthcare services providers market. The bargaining

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power of these healthcare service providers is very weak. The resultant situation is that some service provider may fail to
operate profitably due to high cost structures versus the prices while others enjoy super profits due to their size which gives
them economies of scale that lowers costs against a very strictly imposed pricing structure. A detailed analysis made by J
Silversmith et al, (201 1) of the pricing models available for Healthcare services internationally further clarifies this point.
As the government expenditure on healthcare has continued to decline in recent decades due to the worsening economic
situation, the financial burden for healthcare is now covered by private funders and households (Osika et al, 2010) through
fees and private insurance companies. Per capita actual spending on healthcare by Government has remained below
USD34.00 at USD16.45 as at end of September, 2015 (MoHCC, 2016). This results in diminished intensity in primary
healthcare and this has a significant increase on healthcare costs (Barros, 1998). Respondents complained that some
institutional features had the effect of increasing healthcare costs for example they considered some laboratory tests as
unnecessarily adding to their costs (Kiker and Zeh. 1998). The private laboratories tended to have no standardised prices as
they lacked public information about their services. This supports WHO’s assertion that private healthcare system lack or
unwilling to provide healthcare performance data when required. Furthermore, the lack of a large pool of specialists was
observed as concentrating services in a few centres and this resulted in high costs as specialist are in constant demand and
this domination has the effect of increasing the costs of health care (Franks et al 1992). Respondents generally considered
that prescription drugs were more expensive from private healthcare institutions compared to Government hospitals.

CONCLUSIONS

The study identified that the closest business model in use in the private healthcare services in Zimbabwe is the
STOF model, however this model is still not yet fully developed and there is significant room for improvement.
Furthermore, Government regulation in Zimbabwe is playing a significant role in shaping the business models that are
available in the market. The research also established that technology use in private healthcare is still minimal although
some ICT infrastructure is in place. Therefore the patients may not be benefiting in terms of reduced costs from diagnostic
information systems and the digital revelation (Achiengpong, 2012). The pricing model that is being adopted in the private
healthcare services sector is significantly influenced by the insurance companies. As the contribution of the Zimbabwe
Government has declined the finance burden for healthcare has increased from 23% to 62% in the private healthcare sector
(Osika et al, 2010). While general consultation and standard medical costs may be controlled, the cost situation in other
utilities is rather fluid. In particular specialist services, laboratory and drug costs tend to be high in the private sector
leading to medical tourism to other countries, even at the behest of insurance companies. The study established that the
private sector, following on the strict controls from the Health Professions Act (Chapter 27:19) is fragmented and this has a
major influence on the private healthcare ability to stand as a strong body able to influence costs or reform in their
industry. Furthermore, this also results in significant fragmentation in purchasing and distribution of drugs (WHO, 2008 ).
This may be the source of the patients’ complaints that the private healthcare drugs costs are high.

RECOMMENDATIONS

To minimize costs to patients, the Government could establish shared well equipped state of the art medical
centres of excellence in conjunction with private healthcare companies and these centres could serve the community at low
cost as is currently being offered in medical tourism destination countries such as India, Thailand and Malaysia, according
to the NCPA report (2007).

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The government could also facilitate the flying in of specialists to perform specialist medical services in these
centres of excellence to the local patients and this has the benefit of providing for affordable prices.

Government could also introduce laws that define the minimum size of a healthcare establishment so as to reduce
medical industry fragmentation and help establish medical facilities that have sustainable operational costs. Private
Healthcare companies should make use of the benefits of economies of scale by merging their practices into bigger entities
which lowers their cost structure and enables them to compete effectively on the international medical services market
such as ordering medicines in bulk. Similarly, Private healthcare companies should form their own associations to
represent their interests in matters of common interest like pricing of services, regulation and costs of supplies. This would
have an effect of reducing costs and would be an example of co-opetition strategy as employed by healthcare providers in
Belgium (Tersago & Visnjic, 201 1).

Healthcare services providers are encouraged to close the specialist skills gap by investing in specialist medical
programmes at the University of Zimbabwe School of Medicine Medical Specialist Programme. Furthermore, those who
have access to funding must consider toll manufacturing of drugs with local suppliers who manufacture drugs in order to
reduce the cost of medicine and drugs for patients at the same time helping to build capacity in the local pharmaceuticals
market. A similar project is being run by the United Nations UNIDO arm for Zimbabwe at national level (UNIDO, 2014).
Private healthcare companies are also encouraged to take an interest and to fund research for alternative medicine
programmes research as is done by the Chinhoyi University of Technology Life Long Learning Programme, so as to create
capacity for future savings in the cost of medication and medical supplies. In view of the fact that medical students enter
into private practice early in their careers, medical schools are encouraged to review their School of medicine curriculum
with a view to include business management and ICT modules in their curriculum in order to prepare medical practitioners
for the business world. Furthermore, Universities with medical schools are encouraged to extending medical attachments
students to private medical institutions to allow for diversity of culture in the medical practitioners.

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