Policy, Research, and Exlernal Affairs l WORKING PAPERS Population, Health, and Nutrition Africa Technical Department The World Bank August 1990 WPS 489 Health Insurance in Zaire Donald S. Shepard Taryn Vian and Eckhard F. Kleinau This in-depth study of health insurance schemes in Zaire recom- mends developing more pilot insurance systems in areas where health systems already function - and strengthening existing systems through training, exchange visits, information systems, and technical assistance. Implementing a nationwide health 0 insurance system is not likely to be as successful as decentral- ized, locally managed plans. -. The Policy, Research, and Extemal Affairs Complex distributes PRE Working Papers to disseminate the findings of work in progress and to encourage the exchange of ideas among Bank staff and all others interested in development issues. These papers carry the names of the authors, rflect only their views, and should be used and cited accordingly. The findings, interpretations, and conclusions are the authors' own. They should not be attnbuted to the World Bank, its BoaTd of Directors, its managemcnt, or any of its member cointries Poly, Research, and External Affairs Ppulation, Health, and Nutrition WPS 48g This paper -a product of the Population, Health, and Nutrition Division, Africa Technical Department - was written as part of the Africa Regional Study on Health Financing to aid the ongoing sector adjustmcnt dialoguc ir. Zaire. The study received outside financial support from SIDA, NORAD, and the U.S. Agency for Intemational Development. It was prcsented at a seminar in April 1990. Copies of this paper are availablc free from the World Bank, 1818 H Street NW, Washington DC 20433. Please contact Karol Brown, room J9-112. extension 35073. After identifying 12 systems of health insurance * Simplc control methods, such as printed in Zaire, Shcpard, Vian, and Kleinau prepared premium stamps, detailed descriptions of enroll- detailed case studies of four systems (two urban ces, and the enrollment of entire families helped and two rural) and brief studies of four others. reduce fraud and error. The case studies focused on the terms of the insurancc plans, their organization and manage- * Appropriate investment strategies preserved ment, resourcc mobilization, efficiency, equity, the value of premium income. Investing in client perccptions, and the quality of services. imported drugs was a hedge against crosion of Among the lessons Icamed: the purchasing power of premia. * Plans vary substantially in the services * Financial analysis of the insurance system covcred. Consumers found coveragc of ambula- requires better accounts. Fcw insurance plans tory care attractivc despite substantial premia or had good financial reports of the health delivery required copayments. Only half the plans plan, much Icss of the insurance plan. covcred inpatient care. * A financial guarantor (for example, a * The most successful schemes had modest development organization guarantceing the first premia. year's services) boosts the public's confidence in the insurance system. * Acceptablc quality of service is a precondi- tion for successful implementation of an insur- * Evidence of adverse selection and moral ancc scheme. hazard was found in most plans. Their impact can be moderated by requiring that the entire * The implementation of voluntary schemes family joins or by cnrolling cmployce groups. requircs publicity within the community at the outset. * Informal associations exist that finance members' hcalth care through intcrest-free loans * The risk that insurance plans would be to pay for births, hospitalizations, and other ovcrcharged was limited by the decentralization emergencies. and direct management. The PRE Working Paper Serics disseminates the findings of work under way in thc Bank's Policy, Research, and Extemal AffairsComplex. Anobjective of the scries is to get thcse findings out quickly, even ifprcsentations arc less than fully polished. The findings, intcrprctations, and conclusions in thcsc papers do not necessarily reprcsent official Bank policy. Produced by t-hc PRE Dissemination Center Table of Contents ACKNOWLEDGMENTS ACRONYMS I. INTRODUCTION ............... I A. OBJECTIVES .. I B. HEALTH INSURANCE . I C. HEALTH SECTOR ORGANIZATION AND FINANCING IN ZAIRE .: 3 D. PREVIOUS RELATED WORK . . 4 1. Health Financing Research: User Fees vs. Insurance .4 2. GOZ Commission on the Organization of Insurance Systems 5 E. SUMMARY OF RESEARCH METHODS . . 7 II. CASE STUDIES: DESCRIPTIONS AND IMPACTS. 8 A. CASE STUDY OF BWAMANDA .12 1. Terms of the insurance Plan ..12 2. Organization and Management ..17 3. Resource Mobilization ..20 4. Utilizat-an and Access to Services ..24 B. CASE STUDY OF BOKORO ..28 I. Terms of the Jnsurance Plan ..28 2. Organization and Man&gement . .30 3. Resource Mobilization ..31 4. Utilization and Access ..34 C. CASE STUDY OF ST. ALPHONSE . .37 1. Terms of the Insurance Plan .36 2. Organization and Management . .38 3. Resource Mobilization: Financial Situation of Plan and Center . . 38 4. Utilization ..40 D. CASE STUDY OF CASOP ........................ ............... 44 1. Terms of the Insurance Plan ............ 44 2. Organization and Management .... .. ...... 46 3. Resource Mobilization: Financial Situation of Plan and Clinic ... 47 4. Utilization ............ 47 E. OTHER INSURANCE PLANS ..... 48 1. Reseau Medecins d e Familles i(REMEF) 48 1.1 Terms of the Insurance Plan .48 1.2 Resource Mobilization .49 1.3 Utilization .49 2. Masisi Health Zone Insurance Plan .51 2.1 Terms of the Insurance Plan .50 2.2 Utilization and Success of the Plan .50 3. Mutuelle Union et Prevoyance' (UP) . .51 4. SNHR Employees in Rutshuru . .51 F. INFORMAL ASSOCIATIONS .52 1. Size and Membership .52 2. Contributions .52 3. Reasons for Saving .53 4. Emergency Loan Funds .53 5. Use of Money Lenders for Medical Emergencies .53 6. Roles of Informal Associations .54 i 111. CONCLUSIONS AND RECOMMENDATIONS ............................. 55 A. TERMS OF THE INSURANCE PLAN ........... .. ................. 55 1. The Insurance Schemes Cover Selective Types of Services ....... 55 2. The Most Successful Plans Have Modest Premiums .... ......... 55 B. ORGANIZATION AND MANAGEMENT ...... .... 56 1. An Acceptable Quality of Services Is a Precondition for Insurance .56 2. Voluntary Schemes Have Found It Important to Sensitize the Population .57 3. Committed, Decentralized Management Provides Flexibility and Accountability .57 4. Simple Control Methods Can Reduce Risks of Error or Fraud 57 5. Appropriate Investment Strategies Can Preserve the Value of Premium Income over the Year .58 6. Financial Analysis of the Insurance System Requires Better Accounts .58 7. A Financial Guarantor Can Help Build Confidence in Launching an Insurance System ....................................... 59 C. RESOURCE MOBILIZATION ................. 59 1. Access and Resource Mobilization Motivated Health Insurance Schemes . ................................................. 59 D. UTILIZA.ION AND ACCESS ................ .................... 59 1. Evidence of Adverse Selection and Moral Hazard wag Found, But Plans Minimized Their Impact .............................. 59 2. Systems of Utilization and Cost Control Can Help Make Insurance Affordable .............. ................................ 60 E. INFORMAL ASSOCIATIONS ................ 60 1. Informal Associations Financed Health Care Only Through Emergency Loan Funds .................................... 60 F. STRENGTHENING EXISTING INSURANCE SYSTEMS ..... ......... 61 1. Training . ............................................... 61 2. Exchange Visits ........... ............................... 61 3. Information Systems ....................................... 61 4. Technical Assistance ...................................... 61 G. ESTABLISHMENT OF ADDITIONAL INSURANCE SYSTEMS ........ 62 1. Rural Health Insurance Systems ............................. 62 2. Urban Health Insurance Systems ............................ 62 REFERENCES .63 ANNEXES .65 ANNEX I Description of the Zaire Health Zone Structure And Management Organization .66 ANNEX II List of Prices 1988 and 1989 Bwamanda Reference Hospital and Health Centers .71 ANNEX III Exchange and Inflation Rates .74 ANNEX IV Documentation for Bwamanda Health Insurance Plan .75 ii ACKNOWLEDGMENTS The study team is indebted to the following officials for advice and support: Martha Ainsworth (for supportive management and invaluable comments), A. Edward Elmendorf (AFTPN), Jacques Baudouy (AF3PH), Eliane Karp (AFISD), and Jerome Chevallier (Kinshasa) from the World Bank; Professeur Kabuya, Directeur, Programme d'Ajustement Secteurs Sociaux (?ASS); Mark De Feyter and Paul Cartier of the Medical Section, Belgian Cooperation in Zaire; Mimi Gerniers of Sante Pour Tous Kinshasa; Dr. Duale, (Director), Dr. Frank Baer (Manager), Dr. Nkuni Zinga (Planner), Mme Mbala (Data entry specialist), Kanica Rwdadi Yandu (translator), Steven Brewster (Administrator) of SANRU; and Pere Andre Dhont (Advisor) of the Center for Integrated Development, Kinshasa. The team thanks the following persons for collaboration in designing and collecting data in this study: Dr. Ebenga Lombilo (Charge de mission), Dr. Kokenambeli (Physician), Citoyen Vangi (Accountant), Citoyen Munsie Ivul Ankong (Economist), Citoyenne Kagabo Kayijuka (Sociologist), Citoyenne Lofo Lituka (Demographer), and Citoyenne Walo Onyumbe Lem (Sociologist), Citoyen Mossoko G'be Mogh-Bokolo (Mathematician) of the Mission d'organisation des mutualites; Dr. Freddy Moens (Director of CDI Medical Section), Dr. Angbalo (Chief Physian, Bwamanda Rural Health Zone), Dr. Sema (Medical Director of Bwamanda Hospital), and Citoyen Mombimbo (Administrator-Manager) from Bwamanda Hospital; Citoyen Dungu Tati (Commission de developpement) and Citoyenne Nsona Sala (Nurse and Acting Director) from St. Alphonse; Citoyen Ilunga Betu Kambala (Secretaire National/FNMOS), Dr. Bosasi (Medecin Directeur), Citoyen Mpaka, Administrateur- Gestionnaire from Polyclinique CASOP; Dr. Lokonga Nzeyabe (Medecin Chef de la ZSR), Dr. Kitenge Lubangi, Dr. Idrissa Yaoma (Prefect de l'Institut Technique Medicale de Bokoro), Sr. Vandesande Lieve (Gestionnaire SAFEMK Socures de l'Enfence du Jesus), Cit. Monshe Mbula (Infirmiere Chef de la zone de sante), Cit. Boyulu Vijon (PAC, charge d'annimation), Cit. Mwalenya Bongha (Comptable de SAFEM et de l'hopital), Cit. Moke Bokwande (Comptable du BCZS), Cit. Mputu Ebily (Titulaire du Centre de Sante de Bokoro), Cit. Mputu Nshole (Titulaire du Centre de Sante de Kempa), Dr. Lillquist Agneta (Coordinateur du programme de control de la Lepre de l'eglise baptiste), Cit. Mbengo (President du SECREB), Cit. Nziminse (Vice-President du REB), Cit. Monshe Ngojo (Secretaire du SECREB), Dr. Lahaye Jean Pierre (Medecin Chef de la Cooperation Belge a Kindu) in Bokoro. For assistance in data analysis, the team thanks Pradeep Goel, Francisco Ramos-Gomez and Allison Brucker of the Harvard Institute for International Development. This study was conducted as part of the Africa Regional Studies Program on Health Financing in Sub-Saharan Africa, managed by the Africa Technical Department, Population, Health and Nutrition Division, with financial support from NORAD and SIDA. In addition, this study on Zaire received support from the Social Dimensions of Adjustment Unit, and from the U.S. Agency for International Development. ACRONYMS BCZS Bureau Central de la Zone de Sante BF Belgian Francs CASOP Caisse de Solidarite Ourviere et Paysanne CISL Confederation Internationale des Syndicats Libres CDI Center for Integrated Development CMT Confederation Mondiale du Travail COOPEC Savings and Credit Cooperatives FONAMES Fonds National Medico Sanitaire GOZ Government of Zaire HMO Health Maintenance Organization MCZ Medecin Chef de Zone MUZAS Mutualite Zairoise de la Sante NGO Non-Governmental Organization PAC Programme des Actions Complementaires PASS Programme d'Adjustement des Secteurs Sociaux PRICOR Primary Health Care Operations Research Project PVO Private Voluntary Organization REACH Resources for Child Health Project REMEF Reseau Medecins de Familles SAFEM Service d'Approvisionnement en Fournitures, Equipements et Mcdicaments SANRU Projet de Sante Rurale SECREB Societe Cooperative d'Epargne et de Credit de Bokoro SNHR Service National d'Hydrolique Rural SPTK Sante Pour Tous Kinshasa STD Sexually transmitted disease UNTZ Zairian National Workers Union UPM Union et Prevoyance Mutuelle USAID United States Agency for International Development L INTRODUCTION This study of health insurance systems in Zaire was carried out as part of a larger program of initiatives (described elsewhere) designed to improve the sustainability of health care systems and increase the health status of the Zairian population (1). The objectives of tn' study are presented below, followed by a discussion of the economic aspects of healt, insurance, background information about the heaith sector and health financing systems in Zaire, and highlights of previous related work. The introduction ends with a summary of methods used by the research team to collect and analyze data. A. OBJECTrIVES The major motivations for this study were: 1) to provide information for the ongoing social sector adjustment dialogue in Zaire; and 2) to serve as a case study in the World Bank's Region Str-dy of Health Finance, which is concerned with options for mobilizing additional resources for the health sector. Specifically, the study sought to document different types of insurance systems in Zaire, and to conduct in-depth case studies of several schemes. The in-depth case studies presented in this report evaluate the design, management and operational efficiency of four health insurance programs from both rural and urban areas. The case studies also attempt to analyze the effects of insurance on equity of access, utilization of health care services, and mobilization of financial resources for the health sector. From these analyses, the report draws conclusions about the advantages and disadvantages of health insurance programs as a means of financing health care 3ervices in Zaire, and suggests avenues for future research, policy, and programming initiatives. B. HEALTH INSURANCE Health policy makers often propose health insurance as a possible health financing mechanism for developing countries. In theory, insurance can mobilize additional resources for health without a drain on the public sector and without substantially restricting access; it can also pose potential problems, however, such as over consumption of services ("moral hazard") and increases in medical prices and unit costs. This section reviews economic aspects of insurance to provide a theoretical framework for the evaluation of health insurance systems in Zaire. Health insurance is defined as 'the means by which risks, or uncertain events, are shared between many people." (2) The insurer (or his agent) collects premiums which are used to compensate the insured individuals against financial losses resulting from an insured event. Insurance relies on the fact that people are willing to pay a premium to be compensated for financial losses from an event which might not happen. Insurance also relies on the fact that events that are risky or unpredictable for a given individual, can be highly predictable for large numbers of people. For insurance to be feasible, therefore, risks must be 'pooled' or spread widely among large numbers of people, and the risk events must be independent of each other. (2) Insurance systems are different from prepayment systems because insurance systems provide coverage for uncertain future events, while prepayment systems provide coverage for certain future events. In other words, insurance systems are based on probabilities, which prepayment systems are not. In prepayment systems individuals pay a set amount in advance which entitles each covered individual to consume a specified quantity of services in the l future. The price of the individuai prepayment is set by multiplying the average cost of the covered services times the quantity of services covered, plus a fair share of administrative costs and desired profit. (If prepayment covers several services with different costs, the fee would be calculated by multiplying average cost times quantity for each service, and summing across services.) Individuals may favor prepayment in situations where future events are highly predictable, but future cash flow is low or unpredictable. Demand for prepayment systems does not depend on risk aversion, and has little to do with the individual's assessment of the probability or likeliness of illness (it assumes a probability of 1.0). Insurance systems, on the other hand, require individuals to pay a set amount in advance (the premium) which entitles them to consume services in the future only if those services are needed (i.e. if illness occu-s). Thus an element of uncertainty is involved in insurance. The level of the premium is set by multiplying the probability that an individual will need the covered services (i.e. the probability of illness) times the average cost of the covered services, plus a fair share of administrative costs and desired profit. Premium calculations based on the statistical frequency of disease in the population are called 'actuarially-based" premiums. Demand for health insurance is influenced by the price of the insurance (premium), and individual's assessment of the probability of financial expenditures resulting from illness, the magnitude of those expenditures, the individual's income, and the degree to which he or she is risk adverse. These factors are especially difficult to study in developing countries, where little research has been conducted on issues such as individuals' perceptions of probabilities of loss and willingness to pay to avoid risk. Demand issues are critical in LDCs, however, since many people may lack the means and/or will e: purchase the amount of insurance coverage deemed secially desirable. (2) A further distinction between insurance systems and prepayment schemes is that insurance systems are redist.ibutive. In insurance systems, everyorte may pay the same premium, but only sick individuals will draw the benefits, whereas in prepay nt schemes each participant draws out benefits equally to what he or she paid in initially. Insurance systems can be organized as either 'direct' or 'indirect." In direct insurance systems, the institution responsible for financing the health care services (the insurer) is also the provider, and is responsible for making decisions about how those services are produced, and the amount of services used to treat patient. Direct insurance systems are often more efficient, since there are built-in incentives to keep down the cost of providing services. In indirect systems (also called 'third party payor' systems) the insurer is a separate entity from the health care provider. Since the provider does not have to pay for the services, there is less incentive to manage costs efficiently. Two potcntial problems which can threaten the financial viability of an insurance system are "moral hazard' and madverse selection." these concepts are summarized briefly below [a more detailed discussion may be found in Mills (2)1. 'Moral hazard' is defined as 'the tendency of individuals, once insured, to behave in such a way as to increase the likelihood or size of the risk against which they have insured." Moral hazard refers to the danger that insured individuals, having paid a premium in advence, will demand more services than they would have had they not been covered by insurance. The problem occurs because individuals no longer face a direct payment at the time they consume the services, although there is still a cost to produce those services. This is considered inefficient because the marginal cost of the services consumed is more than the marginal value of those services to the consumer. Moral hazard thus results in an 'over' consumption of health resources. Insurance systems 2 must develop safeguards to reduce moral hazard. Frequently used methods include co- insurance (required contributions from the insured individual for his or her coverage) and deductibles (an initial amount per illness episode which must be paid by the insured iuidividual before the insurance covers the remainder of expenses). While co-insurance and deductibles reduce the danger of moral hazard, they may also discourage insured individuals from seeking care in a timely manner, which can result in larger health care costs later on. (2) A second potential problem facing insurance systems is adver.e selection. Adverse selection occurs when individuals at greater risk of illness are enrolled in an insurance program in lqrger proportions than they are found in the general population. Individuals at greater risk or illness are more likely to desire insurance, since losses from illnesses are more certain events for them. However, if premiums are calculated based on the statistical probability of illness in the general population, an over-enrollment of individuals who are at greater risk of illness will cause costs to be greater than revenue, thus threatening the financial viability of the system. The case studies in this report analyze how successful insurance has been in spreading risks of financial losses associated with catastrophic illness, and in increasing the financial resources available to pay for health care services. The studies also discuss the factors influencing demand for insurance and analyze evidence of moral hazard and adverse selection. C. HEALTH SECTOR ORGANIZATION AND FINANCING IN ZAIRE Although Zaire was left with an extensive health care infrastructure at the time of independence, the health care system deteriorated progressively until in 1977, less than 10% of the population had access to primary health care services. (3) Starting in the 1970's, however, pilot projects were begun which promoted primary health care services such as basic curative care, vaccinations and prenatal care through the establishment of networks of health centers, each network centered around a reference hospital. Often, these hospitals and health centers were managed by a church. In 1975, these projects became the model for a national proposal to create a decentralized system of *health zones." Each would be organized around a reference hospital and contain 10 to 20 satellite health centers, providing integrated primary and secondary-level health care services to populations of approximately 100,000 residents. The proposal became part of Zaire's Five Year Health Plan in 1982, and has been implemented with the support of the Government of Zaire (GOZ), the churches, and many international donors. As of 1989, over 100 of the 306 proposed health zones have been established and are functioning well. In 1987, over 46% of Sh: population had access to primary health care services (3). Appendix I provides a morr, detailed explanation of the organization and management structure of the health zones. Zaire has a range of health care financing systems. The most commoa form of health care financing is user fees, which are administered in a number of ways. A 1986 study of ten health zones revealed that nine zones charged fees per episode of illi ess to financing ambulatory curative care. (4) With this payment system, follow-up consultations were provided at no additional charge. In three of these nine zones, drugs and laboratory test were also included in the episode price. In most health zones, the price of inpatient care is calculated according to the number and types of services and procedures provided (drugs, exams, bec. days, etc.). The per-case pricing methodology in practice at Bwamanda Hospital (described in the first case study in Section II) is encountered less frequently. 3 Two health zones in the Kivu Region, Kasongo and Kindu, have employed a s stem of pricing per episode for both ambulatory and inpatient care. It permits the patient to receive all services required, for one set fee. The hospital charges a referral fee to the health center for each hospitalized case referred. While this aystem achieves an important social objective of assuring continuity of care and access for people who might not otherwise be able to afford inpatient care, it has not proved financially viable. The nospital referral fee reportedly is inadequate to cover its operating costs, but the set fee c'nnot be raised without excluding ambulatory patients with minor illnesses. Both zones rely on substantial external subsidies from international donors to pay operating costs. According to the manager of the USAID-financed Basic Rural Health Project (SANRU), several zones have also initiated prepayment systems using health cards. Area residents are allowed to purchase the health card at a set price which entitles the bearer to a fixed number of curative care visits. The price is discounted slightly from the full price which walk-in patients must pay. The advantage of this system is not necessarily the cost saving (since inflation may offset any benefits from price discounts), but rather that it provides farmers with a way of paying for health care when cash is available. In the formal sector, Zairian laws require that employers pay for health care services for their employees and employee's dependents. Firm employees and their dependents represent about 18% to 27% of the country's 31 million population, according to two recent studies (1,S). Some large enterprises own and run their own health facilities, where they provide services to employees and dependents at no charge. Other firms contract with health zones or other private providers to treat employees. Finally, there are several health insurance programs functioning in Zaire, most managed by non-profit or private organizations. These programs are the subject of this report. D. PREVIOUS RELATED WORK I. Health Financing Research: User Fees vs. Insurance Considerable research and policy analysis on health financing has been conducted in Zaire, including studies sponsored by the GOZ, the World Bank, USAID/Kinshasa, AID's PRICOR and REACH Projects, and other donors (1, 3-16). The Health Zones Financing Study, sponsorvd. by the SANRU Project and REACH Project in 1986, examined the financial performance *.! ten well-functioning health zones, one in each region of the country. The study revealed that approximately 80 percent of health zone operating expenses were being covered by user fees. The remaining expenses were financed through government and private subsidies, in equal proportions (4). Almost no ambulatory care is provided free of charge to the general public in Zaire. These surprising results provided evidence that Zairians were willing and able to pay for health care services, and indicated the importance of the decentralized community-managed health zone organizational structure. Other studies have examined the different incentives of fee-per-visit versus fee-per-episode payment systems (11), the effects of inflation on health zone pricing policies (7), determinants of consumer demand for health care services (8,16) and deficiencies in health zones' financial management information systems (15). This research has clearly demonstrated that user fee systems have increased the financial resources available to the public health sector, resulting in an increase of utilization of health care services by the population. Several troubling issues remain, however. Health financing experts have questioned the 4 equity and financial viability o, health systems which rely so heavily on user fees, especially with regard to expensive inpatient care (17-20). Bad debt is a documented problem in inpatient care facilities, and is the primary reason why hospitals have the lowest rate of cost recovery of all health iacilities in Zaire (4). For tnese reasons, a recent study concluded that user fees may not be the optimal financing mechanism for inpatient care (5). In theory, insurance programs may avoid these problems, since the premiums are based on the statistical probability of illness, and are therefore set at a fraction of the avcrage cost of a hospitalization. The population may be more willing and is certainly more ab!e to pay the price of an insurance premium than to pay the full cost of inpatient care. Thus, compared with the current user fee system, a hospital insurance program has the potential to mobilize grcater and more steady financial resourt'. while providing protection to individuals against the enormous burden of catastrophic illness. As early as 1986, rcscarchers in Zaire identified insurance systems and pre-paid plans as an additional health financing mechanism which could help protect individuals against the cots of catastrophic illness, and at the same time provide a steady source of increased revenue for the health sector (4). Most recently, a paper commissioned by the World Bank in the course of social sector adjustment work reiterated the potential advantages of health insurance systems in Zaire, especially in comparison with the current, almost universal systems of user fees for inpatient services (5). The study noted that Zairians can expect to have high inpatient expenditures if they fall ill and require hospitalization, given the user fees now in place. Perceiving that they will be faced with such high expenditures when hospitalized, sick individuals can take three actions: 1) avoid sceking care at all; 2) obtain care and spend a large portion of annual disposable income or sell household assets to pay for it; or 3) obtain care and not pay for it, thus increasing the hospital's burden of bad debt. Whatever option is selected, the outcome is negative. In the first two cases, the individual's welfare is harmed by not seeking necessary care, or by being forced to spend a large portion of very limited household resources on one episode or treatment. In the last case, the financial sustainability of the health care provider is undermined by the extra burden of frec care provided to inpatients. Given the success of Zaire's user fee system in mobilizing resources to finance ambulatory care, the case for insurance programs for ambulatory care is less strong. Insurance may be desirable, however, as a way to stimulate demand for services, if under-utilization is a perceived problem. 2. GOZ Commission on the Organization of Insurance Systems At the same time, the Government of Zaire has sh, ' i great concern for insurance programs. In 1989, the Conseil Executif commissioned an insurance systems study (Mission d'Organisation des Mutualites) which included four parts: I) An inventory of existing *mutual associations" (a term that includes many different types of formal and informal clubs and cooperatives); 2) A public opinion survey; 3) Plans for proposed changes in laws regarding the organization of insurance in Zaire; 4) Options for pilot testing and alternatives for organization, financing, training and promotion of insurance programs (13). 5 Results of the inventory and cpinion survey are summarized briefly below. Some of the othei proposals suggested by the Commission are mentioned later in this report.: In 1989, the Commission attempted to conduct an inventory of all mutual associations in Zaire. Difficulties in communication linmited the focus to about 1,000 associations in t1-e Kinshasa area, however. A total of 562 associations (mostly informal) completed the survey form. Some associations were contacted directly; others were identified through government administrative channels and by announcements on public radio. The survey defined a mutual association very loosely. All types of formal and informal groups were targeted, including cultural groups, agricultural and handicraft cooperatives, health zones, and savings organizations. The inventory found that most informal associations were small (less than 50 members) and require a monthly contribution of between 100 to 500 Z in order to finance certain benefits. About 30% of the associations surveyed provided financial assistance in case of illness. Finan..al assistance was also provided for events such as a death in the family, marriage, birth, or other fintancial problems. The GOZ findings about informal associations were similar to the findings of the World Bank team research, discussed in Section I. The inventory a!so described ten, more formal assoc.ations (numbers I through 10) which offer or a-e planning to offer some form of health insurance. In the course of the present study, two additional systems were identified (number 11 and 12). All 12 systems are described in Section II. 1. Bwamanda Health Zone, Equateur Region 2. Bokoro Hlealth Zone, Bandundu Region 3. St. Alphonse Health Center, Kinshasa 4. Caisse de Solidarite Ouvriere et Paysanne (CASOP), Kinshasa 5. Reseau Medecins de Familles (REMEF), Kinshasa 6. Masisi Health Zone, Kivu Region 7. Mutuelle 'Union et Prtvoyance' (UPM), Kinshasa 8. Mutualite de Solidarite Chretienne, Kinshasa 9. MUZAS, Kinshasa 10. LETISSA, Kinshasa I. Sona Bata Health Zone 12. SNHR Employee Cooperative in Rutshuru. The public opinion survey, also in 1989, interviewed 850 individuals in Kinshasa from different socio-economic levels and professional groups to learn about the Prevalence of membership in mutual associations and perceived advantages and disadvantages to membership. Sixty-three percent of respondents were members of some sort of mutual association (not necessarily related to health). About half of current members responded that they were satisfied with how the association operated. For those who were dissatisfied, the key reasons were financial: either a lack of sufficient financial resources, or irregularity of contributions by members. The survey also detailed reasons why people join mutual associations, and what role members saw for the State. On the latter question, most respondents saw the State's role as one of 'encadremento rather than supervision or management. I This report does not attenpt to analyze the legal changes proposed in the Commission report. While legal issues will become very important as the insurance industry develops, they were not considered of primary interest for the initial evaluation of existing systems. 6 E. SUMMARY OF R_EARCH METHODS Duririg the three-week study, the team collaborated closely with the members of the GOZ Commission. The team conductece interviews with officials from various government and non-governmental agencies, including the World Bank office and the Programme d'adjustement des Secteurs Sociaux (PASS) project in Kinshasa, USAID and the USAID- sponsored Sante Rural (SANRU) Basic Rural Health Project, Zaire's Expanded Immunization Program (EPI), the Cooperation Medicale Belge au Zaire, Projet Sante Pour Tous, Kinshasa (SPTK), and the Center for Integrated Development. The team reviewed data already collected by the GOZ Commission, in particular the opinion survey and sur-cy of existing mutual associations. Through this review, four health insurance plans were selected for in-depth study: two offered by rural health zones (Bwamanda arnd Bokoro) and two which cover ambulatory care services in Kinshasa (CASOP, offered by the Syndicat National UNTZA, and St. Alphonse, a community-initiated plan assisted by SPTK and the Catholic Church). More information about how the case studies were selected is presented in Section 11. Members of the team visited Bwamanda and Bokoro, interviewing medical staff there to obtain detailed information about organization and management of the insurance plans, premiums and enrollment rates, etc. 71 hospital patients in Bwamanda and Bokoro, and 26 residents in Bokoro Zone were surveyed to obtain information about satisfaction with the program, and to compare characteristics of members and non-members. Financial and utilization records were reviewed in both zones, to evaluate evidence of moral hazard and/or adverse selection, and to measure the effects of health insurance on the financial condition of health facilities and the health status of the population. In Kinshasa, team members collected descriptive information and reviewed financial and utilization data from the facilities in which these plans were based (St. Alphonse and CASOP). A 205-patient survey was also conducted. Finally, team members visited several other insurance systems in the Kinshasa area. To supplement information about formal hcalth insurance plans, information was gathered from 22 informal savings associations (uuikelemba' and wmoziki'), which sometimes come to the aid of members with catastrophic illness. 7 IL CASE STUDIES DESCRIPTIONS AND IMACTS This section provides information about eight insurance programs, seven of which were selected from the ten mutual associations identified by the GOZ Commission as offering health insurance programs. The eight insurance programs (and their original number) are: l. Bwamanda Health Zone 2. Bokoro Health Zone 3. St. Alphonse Health Center 4. Caisse de Solidarite Ouvriere et Paysanne (CASOP) 5. Reseau Medecins de Familles (REMEEF) 6. Masisi Health Zone 7. Mutuelle "Union et Prevoyance" (UPM) 12. SNHR Employee Cooperative in Rutshuru The other four known insurance programs (numbers 8 through ll) were not reviewed here either because plan officials were not available for interviews no. 8 (Mutualite de Solidarite Chretienne, and no. 10 LETISSA) or because the systems are not functional (no. 9 MUZAS, and no. II Sona Bata)." From those programs reviewed, the team selected associations I through 4 for in-depth case analysis. These schemes were chosen for several reasons. First, the team wanted to study insurance systems which had been operating for at least a year, and for which information about utilization and financial performance was available. Program no. 12, a small cooperative, may have been less than a year old. The team wanted enrollment of at least 1000 members so that utilization rates would be stable. This criterion eliminated programs nos. S (REMEF), 7 (UMP), and again 12 (SNHR cooperative). In addition, the team wanted to analyze insurance systems in both rural and urban settings, covering different types of care (e.g. ambulatory, hospital). Finally, travel and communications were clearly a constraint, given the short duration of the study. The health insurance plan in the rural zone of Masisi was not selected for this reason. Tables I1.1 through 11.3 summarize pertinent characteristics of the four plans. Each of the case studies then provides detailed description of (l) the terms of the insurance, (2) organization and management, (3) effect on resource mobilization, and (4) effects on utilization and access. A brief sketch of the remaining four plans (nos. S tnrough 7 and 12) follows. The section also includes information about informal savings associations, some of which offer financial assistance to members in times of need. 2 MUZAS is a proposed centralized national health insurance plan, described in the GOZ Commission report. 8 Table 11.1 Description of Models in Case Studies, Part 1 NAME OF PLAN BWANANDA ST. ALPHONSE 8OKORO HEALTH ZONE CASOP/UNTZA INSURANCE PLAN INSUJRANCE PLAN "ABONNEMENT" ......... .. .. . .... . ...................... ...... I- -- - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - REGION Equateur Kinshase Bandundu Kinshasa RURAL/URBAN Rural Urban Rural Urban TYPE OF MANAGEMENT Health Zone One health center Health Zone UNTZA Assisted by the Center uithin a health Assisted by medical staff (Zairian National for Integrated Development zone: assisted by of the Belium Cooperation Workers Union) (CDI), a project started SPTK and Catholic by Belgian votunteers parish DATE STARTED April, 1986 February, 1987 1985 1968 ELIGIBLE 1986: 118,612 1989: 10,000 residents of 1986: 112,911 1989: 3 million (pop. POPULATION 1987: 125,480 catchments area of St 1987: 116,815 of the city of Kinshasa) 1988: 130,000 Alphonse Health Center 1988: 109,685 1989: 134,680 1988: 110,000 NLWBER OF MEMBERS 1986: 32,750 (28X) 1987-89: cumulative 1988: 4,410 (4X) (ENROLLMENT RATE) 1987: 58,100 (46X) enrollees 1689 (17X) 1989: 4,444 (4%) 1988: 80.595 (62X) 1989: 620 (6X) 1989: 6,691 in Kinshasa 1989: 81,142 (60X) (0.2X) SERVICES Hospital: all types Curative care outpatient Primary outpatient care Outpatient curative care COVERED of haspitalization inc. visits at a fixed price including most drugs, at a flat rate per day deliveries (w/prenatal per episode, including laboratory exams, forms, including essential drugs care). Health center: basic drugs and up to 4 consultations at reference chronic care treatment follow-up visits hospital if referred. SERVICES Hospital: deliveries Laboratory exan, special Hospital irpatient care, Laboratory tests; special NOT COVERED w/o prenatal care; drugs above nor al health chronic diseases, STDs, drugs not included in private doctor visits center stock. Doesn't deliveries, Preventative health center drug List Health center: all cover hospital care, del- care, MCH, FP, antibiotics hospital inpatient care; care except chronic iveries, or preventive care & injections deliveries, Ante-natal care, MCH UNIT CF ENROLLMENT Individual; however, if Individuat Individual, however, if one Femily membrship one eiber of a family membr of a family joins, joins, all mebers must alt mist join. join 9 Table 11.2 Description of Models in Case Studies, Part 2 ............ ....... ....... .................................................................................................................. NAME OF PLAN BWANANDA ST. ALPHONSE 80YORO HEALTH ZONE CASOP/UNTZA INSURANCE PLAN INSURANCE PLAN "ABONNEMENTO ................... ........................... ........................... ........................... ......................... PREMIUM PRICE Premiun per household mom. 1987: 50 2 1985 1989: 600 2 1989: 100-200 Z/month PER YEAR 186: 20 Z 1988: 100 Z 1989: 1,200 Z One time fee of 100 Z for 1987: 30 Z 1989: 300 Z Paid 100X by mpaoyer. wemership booktet 1989: 125 Z 00 ALL MEMBERS Yes Yes Yes No. 3 tevets of contribu- FACE THE SAKE PRICE tions depending on income CO-PAYMENTS 20X for slt hospital meebers pay a flat fee 25 X for covered services; Meybers pay a fee per day and health center serv. per episode (500 Z In 1989) All excluded services (450 Z for indiv. members except deliveries w/ Vatid for 5 days. are charged at full rates. in 1989). prenatal care (free) Paid 100X by rployer. DEDUCTIBLES None None Norne None PRICES FACED BY Uninsured are treated Non-merkers pay per visit. Uninsured are treated at Uninsured are treated at UNINSURED at full charges. Three Price includes basic drugs. futl charges. higher prices payor categories for In 1989, first visitu400 Z, non-memoers (1) employer- follow-up visits * 150 2 billed, (2) non-resident (3) all others LIMIT ON MAXIKMI No Five day timit for episode. At discretion of health No SERVICES TO A personrel in case of MEMBER excessivw utilization. UTILIZATION REVIEW/ No No Each treatment Episode is No CASE MANAGEXENT noted on *eSbership docu- ment, including drugs coauwed. QUALITY OF CARE Stockouts rare; several Stockouts rare; no doctors; Stockouts rare, several Stockouts rare, two doctors and well-trained several uell-trained nurses doctors end well-trained doctors rd several well- rnirses (some expatriates) (some expatriates); nurses (same *xpatriates); trained nurses; infra- infrastructure good. infrastructure good. infrastructure good. structure fair. VOLUNTARY/ Votuntary; but if one Votuntary Voluntary; but if one Voluntary except if COMPULSORY family wmbeer joins, fmily enIer Joins, compeny joins, employees all mist join all *ut join. must pay contribution TYPE OF INSURANCE Direct, offered by provider Direct, offered by provider Direct, offered by provider Direct but my change ACCOJNTING Irsurance pLan aectg kept Accounting for plan Is Accounting for plan is Accounting for plan is seperate. Hosp. & heaLth co ired with health center combined with health center cebined with polyctinic centers bill the plan for accounting. accounting. accounting in same aspects services rendered. ADMINISTRATIVE 5.7U of premiues Not distinguished from Not knoum Not known COSTS health center adin. 10 Table 11.3 Description of Models In Case Studies, Part 3 NAKE OF PLAN BWAMANDA ST. ALPHONSE BOKORO HEALTH ZONE CASOP/UNTZA INSURANCE PLAN INSURANCE PLAN "AAONNEMENTU .................. .......................... ....................... ........................... .................. VERIFICATION OF AtL hospital cases must Clerk checks meitership Registration form with all Present meebership card INSURANCE STATUS be referred from HC. card and compares to member names exists In (with photo) or give MC checks im eership card national ID card. dupticate at heaLth center employee ID number against family health Sautimes clerk checks and with household. Family card. Clerk at hosp. aelso against mwb, register form presented during checks card against ember- consultation. ship register ENROLLMENT PERIOD 8 weeks per yr, Feb-Apr, Any time during year, Any time duping year. Any time during year. following harvest period except sick people aren't aLlowed to join and receive care immedistely at emaber- rates DURATION OF BENEFIT One year One year One year As long as monthly dues paid INVESTMENT OF FUND Fuid Is invested at CDI Funds are kept at perish. Local expenses are dedcted None (2.5-3X interest per month) Not Invested. from revenues, balence or loaned to pharmacy to entirely used for referred purchase drugs. patients and central operating costs. FINANCIAL SITUATION Every year, plan has Unknown Underfinanced prior to 1989 Unknown OF PLAN covered expnses. In 1989 10X morkup at present plan will need to use utilization rate of members surplus from previous years to cover expenses TOTAL PLAN REVENUE 1986: unknown Unknown 1986: unknown 1989: 403,980 Z (INCL. INTEREST) 1987: 2,245,752 Z 1987: unkrxmn 1988: 4,958,855 Z 1988: 2,646,000 Z 1989: 10,887,846 Z (proj.) 1989: 5,332,800 Z (proj.) TOTAL PLAN EXPENSES 1986: unknown Unknown UnknIwn Unknown 1987: 1,736,878 Z 1988: 4,802,190 Z 1989: 11,125,106 Z (proj.) FINANCIAL SITUATION Cost recovery st hospitel Highly profitable. Over Health centers cover their Unknown, but looks OF HEALTH FACILITY increased by 30X between 50 excess revenue over operating expenses inc. profitable 185 and 1988. expenses In 1989 supervision and Health centers recover over (projected). adeinistration by BCZS lOOK of costs. CHANGES IN Hoepitel utilization rates Unknown Plan mebers have 11 to 12 MNasers seem to make more UTILIZATION: higher for members then for times higher utilization follov-Lp visits than nor-mmsbers. than uminsured & urWmloyed non-mtbers 4% (mubers) conume 31X ................................................................................................................................... 11 A. CASE STUDY OF BWAMANDA The health zone of Bwamanda, located in the Equateur Region of Zaire, operates under the medical services of the Center for Integrated Development (CDI) of Bwamanda. The CDI was started in 1969 with assistance from Belgian missionaries, to support economic and social development, including agriculture, health, nutrition, and infrastructure. The health zone's 1989 population of 134,682 is served by a 156-bed reference hospital, 20 comprehensive health centers, and two smaller health posts. The following section gives a brief introduction to the insurance plan operating in Bwamanda, and its context. The section describes the terms of the insurance package, charactcristics of the population served, and the organization and management of the plan. Subsequent sections describe the financial condition of the insurance plan and the hospital, and analyze issues of efficiency, cquity, and demand for services. This discussion draws on previous work by health zone staff and other research teams, reported in several documcnts; Moens (1988), Bitran (1986), Vian and Nsembani (1986), and Bwamanda Health Zone (1985-1988) (Annual Reports of the Health Zone). 1. Terms of the Insurance Plan Several concerns led decision makers to consider the development of an insurance plan as a health financing option for the zone of Bwamanda. Most important, the zone's medical staff wished to increase economic access to health care and to improve the hospital's financial situation. Regarding access, fluctuations in income due to seasonality of crops meant that it was not easy for individuals to pay the full cost of a hospitalization. Medical staff were also concerned that individuals who had becn referred to the hospital were delaying several days to come, in order to gather enough money to pay for the care (14). Regarding the financial situation of the hospital, a study in 1986 showed that the hospital had recovered less than half of its operating expenses through user fees in 1985. Compared to the eight other hospitals analyzed by Bitran et al, Bwamanda performed the worst in share of costs recovered from patients (4). The process of designing the insurance plan included considerable participation from both medical staff (including health center nurses) and the communities. First , hospital staff discussed the acceptability of the plan with health center nurses. Through these workshops discussions, the basic parameters of the plan were set, for example, a small so-payment, no deductible, and annual collection rather than semi-annual premiums. The idea of covering ambulatory care through the insurance plan was also discussed during these preliminary workshops. Overwhelmingly, the nurses rejected this idea because they believed it would result in overutilization of medical services (14). At the level of the community, meetings were held to explain the basic elements of the proposed insurance plan, and to ask community members for their preferences regarding premium and co-payment levels. Presented with two options, the communities expressed preference for a higher premium and lower co-payment (14). Health zone staff regularly solicit community opinion regarding the health insurance plan, through the CDI's community development committees. The Bwamanda insurance plan covers hospitalizations (including deliveries), dental extractions, and ambulatory surgery (circumcisions) at the Bwamanda Hospital. Covered care span six clinical services: Pediatrics Internal medicine 12 Intensive care Surgery Obstetrics (where mother has attended prenatal convsultations) Gynecology The insurance plan also covers the cost of treatment of chronic illness at the health center and health post. Each clinical service has one to four sub-departments, bringing the total number of covered hospital clinical services to 14. Two add-tional clinical services have been designated by the hospital but are not covered by the insurance plan. These are: 1) private doctor visit or physical examination, and 2) deliveries of mothers not enrolled in prenatal consultations. Including these two services, the hospitil has a total of 16 clinical services. The Bwamanda hospital has employed a system of flat rate charges for episodes of illness or hospitalization for 10 years. The charge varies by payor category. A list of hospital services, along with pricing information according to payor category, is attached in Annex II. Each price covers all resources required for treating the inpatient episode, including nursing, doctor visits, laboratory and X-rays, pharmacy, operating room time, housekeeping and supervised day treatment, etc. The standard price given in column A, applies to an uninsured patient included in the zone census. A non-member (column B) generally pays 20% of the standard price. People from outside the Zone (i.e. not in the census) generally pay twice the standard price; employed persons whose employer pays directly pay 250% of the standard price. The population eligible to join the insurance plan includes all residents of the health zone of Bwamanda. Villages are often very large (1,000 to 2,000 inhabitants); the population density is 54 persons per square kilometer. Health centers usually serve between 4,000 to 8,000 people, and 99% of the population lives within 7 kilometers of a health center (14). According to the health zone census, about 17% of the population are children under five. In a 1987 survey of 518 households, about half the households reported annual revenue of less than 7,500 Zaires ($58).' The same survey showed an average household contained five children and 7 to 8 members overall. About 90% of the population of the health zone are farmers. The major crops are coffee, soy beans, corn, cotton, peanuts and cassava. In some parts of the zone, fishing is an important activity. About 4.6% of the zone's population are salaried employees and their families. These employees work for private or parastatal companies. The largest of these employers is the CDI itself, with 617 employees (a total of 3,480 covered beneficiaries). An unknown number of residents earn salaries working for small shops or other small businesses. Table A.l shows the evolution of membership in the insurance plan, from 1986 to 1989. To better characterize insured and uninsured patients, the study team interviewed 50 of the 196 hospitalized patients in a systematic survey hospitalized on November 2 or November 3, 1989. The questionnaire (in Lingala) is in Annex V. Table A.2 compares the insured and uninsured inpatients who used the hospital. Insured patients were more like'v to be female and were less educated. Otherwise, there were no noticeable differences. As only one respondent was employed, it was not possible to separate ordinary uninsured and employed 3 The Zaire, the unit of currency of Zaire, has been subject to rapid inflation. As of the time of this study (mid-October, 1989) one US dollar was worth 430 Z officially and about 470 Z on the parallel market. 13 Table A.1 Swanmnda Health Insurance Plan Menbership Rates 1986 1989 ......................... ............................... 1986 1987 1988 1989 ............................. .............................................. ....... ..................... Neffbers 32750 58100 80595 81142 Total Population 118612 125480 130000 134680 Percentage enrolled 27.6 46.3X 62.02 60.2X Change in enrollment rate (prcentage) 18.72 15.72 -1.72 ...................... .......................................... ................ *1989 population estimated based on growth rate of 3.6X patients. Table V.1 in Annex V analyzes missing data to show how various ambiguities in the survey were resolved. Table A.2 Survey of 50 Bwamanda HospitaL Patients: Frequ ncies ................................................. .. .... X of Respondents: Numbers Insured Uninsured used Characteristic (0a29) (0Zi) .................. ...................................... ..... ...................... Gender: FemaLe 69 X 43X S0 Nale 31X 57X What do you think of the idea of health insurance? Good 1002 61X S0 Don't know 02 10l Could you pay 10,000 Zaire for an 50 illress episode requiring minor surgery in a hospital? Yes 522 43X No or no response 48X 482 How would you pay this unot? 35 Installment 252 272 Cash 752 73X Uhere would you get the money? 48 Cah from houehold 72 102 Sav!ng club or association 42 02 By selling household itwn _32 252 outside the hou shold Contribution of a fmi ly m*bers 7r 402 other 362 252 No response 32 02 Did you go to school? so Not at all 662 382 Pr1mary school, 1-3 years 17X 192 Primry school, 4-6 years 102 142 Secondary school 7r 29X 14 Does your househctd grow: Soya 76X 76X 50 Corn 93X 86S 50 Coffee 45X 52X 50 Does your houschold have a: Radio a 5S 50 Sewing machine 10% 10X 50 Bicycle 34X 19X 50 The insarance premium for 1989 was set at 125 Z ($0.35) per person. In theory, if a family wishes to enroll in the plan, all members of the family must be enrolled, although this practice is not always followed (see discussion, section 2). The size and composition of the family are determined from the family health card, which is filled out for every family in the zone during the health zone census completed every two years. All adults wishing to enroll in the plan face the same premium. Table A.3 shows premiums for 1986-1989: Table A.3 Amual Premium for Bwamada Insurance Plin, Per Person ' ... ........ ............................................. NOMINAL 1986 1986 YEAR ZAIRES DOLLARS I ZAIRES DOLLARS .................................................... 1986 20 s0.33 20 $0.33 1987 30 S0.23 22.9 $0.38 1988 so 50.27 24.6 50.40 1989 125 S0.35 28.8 50.47 'Exchange rates and infiation rates are found in Anex 111. The insurance plan employs co-payments but no deductibles. In 1989 the co-payment was established at 20 percent of the standard flat-rate charge for 13 of the 14 covered charge categories. (Payor A, the most common payment category, is for non-insured zone residents whose health care is not paid through hospital billing to an employer, as described later in this section.) The exception is obstetrical care to women who were enrolled in prenatal care; in these cases, no co-payment is charged. The 20 percent co-payment applies to treatment of chronic illness cases at the health center level as well. During 1988, the health zone experimented with a system of variable rates for co-payment, depending on the distance from the hospital. Plan members who lived furthest (over 50 km) away from the hospital of the patient were charged only a 5% co-payment, compared to 10 percent for those living 25 to 50 km and 20 percent for those who lived closest (under 25 km). The plan asked nurses to make a special effort at enrollment especially in outlying areas. When the hospital staff reviewed the insurance plan at the end of 1988, they thought that the system had not increased access for members living far from the hospital. It was difficult to control, as well, leading the zone to abandon it in 1989. According to Figure A.l, however, which shows the relationships between insurance status and distance, the 1988 program changes (either the variable co-payment rates, the stepped-up awareness campaign, or both) may have influenced the decision of distant residents to enroll in the program. Enrollment declined less with distance from Bwamanda center in 1988 than in the three other years of the insurance plan. There is a clear decrease of the membership rate the further the villages are away from Bwamanda for 1986, 1987 and 1989. Regression analysis confirmed that the slope 15 was significantly negative (p < .05) for all the years except 1988. There is no evidence that the stepped-up awareness campaign was effective for the close-in health centers. The enrollment rate of villages about 75 km away was 35 percentage points higher than it would have been based on patterns from other years. The squares in Figure A.l show the actual observations for 1989 as an indication of the variability about the overall pattern. Each observation corresponds to one of the 21 health centers. DISTANCE AND INSURANCE MEMBERSHIP Btauunda Inurance Plan 90 r 70 - 0 O 60 j 50 = 0C 40- 30- 20- 10 0 r 0 20 40 80 10 100 DiStance frcm kMrMs (km) o 1969 i. 1999 o Igo A 1987 x lsee Figure A.l The Bwamanda plan has two important controls on covered expenses. First, all covered services are provided only by referral. Second, the flat rate charges limit the plan's expenses for each admission. Since the insurance system is offered by the provider, there is no reimbursement system and thus no "cap" on spending use by the member. There are no limits placed on care-givers regarding the maximum number of services (patient days, laboratory tests, etc.) or expenses used to treat a patient. Standard treatment protocols do exist, and the doctors and other medical staff make efforts to follow them. There are no systems for utilization review or case management, however. The insurance plan is voluntary; however, if one member of a family wishes to join, all family members are required to pay the premium. This is intended to reduce adverse selection, where only those who know they will probably need insurance subscribe to the plan. 16 The hospital continues to treat the uninsured, but at prices which are sometimes higher than the full payment on behalf of insured residents. There are three types of uninsured patients treated at the hospital: Payor Category C: non- residents; Payor Category D: salaried employees, and their families, whose health care expenses are paid through hospital billing to the employer; and Payor Category A: health zone residents who do not fall into Payor Category D and decided not to join the insurance plan. Members of the insurance plan fall into Payor Category B. For the purposes of this discussion, therefore, four categories of patients exist: PAYOR CATEGORY DESCRIPTION ... ......... ................................................. A Uninsured health zone residents without an employer who pays the health zone directly for employee care B Insured residents C Non-residents (not eligible for insurance plan) DA Employees whose employer pays the health zone directly for services As noted earlier, a full list of prices of hospital services according to payor category is provided in Annex II. Annex IV discusses procedures for fee collection cnd describes how free care and bad debt are handled. Patients who cannot afford to pay are not turned away from Bwamanda Hospital, but are treated and allowed to pay in installments. 2. Organization and Management The insurance plan began enrollment in April, 1986. During the first two years of operation, the insurance plan covered onty hospital services; coverage of chronic illness treatment at the health center level was added in 1988. The Bwamanda insurance plan is offered by the provider -- the Bwamanda Rural Health Zone. Accounting for the insurance plan is kept separate from that of the health zone. The price of the premium is set both to be 'affordable', and to cover the expected hospital 4 All employers are responsible by law under the 'Code de Travail' for providing or paying for the health care services for their employees. Some employers (in particular, the Government of Zaire) do not respect this law. Bwamanda residents who are salaried government employees therefore fall into payor categories A or B, depending on their decision to join the insurance plan. Other employers may decide to reimburse employees for their expenses (for example, employees in small shops, and domestic help), rather than having the hospital bill the employer. In such a case, the employee would again fall into category A or B, depending on whether the employer encouraged the employee to join the health insurance plan. The prices for payor category D are only valid for those employers who have an agreement with the hospital and other health zone facilities whereby the health zone bills the employer for the services provided. Category D includes mostly large, formal Fcctor employers. 17 operating costs (excluding depreciation) incurred by beneficiaries. Capital costs were considered the responsibility of the government and donors. To calculate the each new year's premium, the medical staff (primarily the Director of the CDI's medical service) first build the budget for the new year, based on historical costs corrected for historical inflation, and incorporating estimates about the next year's inflation rate, further devaluation of the zaire, and other budget parameters. The staff then divide the estimated operating costs by the total population to obtain the per capita cost of hospitalization for the next year. Using various assumptions about the percentage of the population likely to enroll in the plan, and the expected revenue from uninsured patients (who would pay full charges), the zone calculates projected cost recovery for the hospital as a whole. The premium for the health insurance plan is then set through discussions involving the whole staff and incorporating social goals as well as cost recovery objectives. For example, the projected premium is compared with the price of two kilograms of soy beans (a commonly produced crop), as a measure of affordability. The medical staff tries to assure that the premium is sufficiently large to cover the claims of the beneficiaries, with some margin of error. Financial records were not kept accurately the first year, although the plan seemed to cover costs. Using Bitran's data (4), the cost per hospitalization in 1985 vsas 3:6 Z. (1,803,844 Z total hospital operating costs excluding depreciation divided by 5,711 hospitalizations.) The probability of being hospitalized in 1985 was 5% (5,711 hospitalizations divided by 114,410 inhabitants). Therefore, the expected cost of hospitalization per inhabitanit was 15.8 Z (5% x 316). The premium was set 21% higher than the expected cost, presumably to cover administrative costs, and possible adverse selection. The premium is collected once a year, at harvest time. There are two harvest periods in the Bwamanda zone; one in July-August, the other in January-February. When communities were asked when they would prefer to make the premium payment, they overwhelmingly preferred the months following the second harvest period (March to April), because they needed cash in August to pay for school expenses (14). Collection of the premium takes place during a six-to-eight week period in February through April. Prior to this, several preparatory meetings are held with health center staff to orient them to any new changes in plan premiums and administrative procedures, and to present them with the time table and control procedures for the registration period. Residents enroll in the insurance plan at their health center. When the payment is made, a stamp printed with the name of the health zone and the price is affixed on the individual's medical identity card. The medical card includes the individual's name, village, and enrollment number, and allows space for critical medical events to be registered (vaccinations, prenatal consultations, hospitalizations, etc.). A second stamp, with different color print, is placed on the family health card, which stays at the health center. The health center nurse signs his/her initials over the stamp on the medical card, taking care that the signature also touches the card, to avoid cases of fraud where unsold stamps are stolen and affixed to cards, or stamps are moved from one person's card to another's. The health center nurse also registers information about each enrollee in special notebooks, which are organized by village. These notebooks are then used for control purposes at the hospital level to control that the bearer of an insurance card is really the person named who registered. 5 Annex IV provides examples of many of the documents described below and in the subsequent section on identification of the uninsured. 18 During the enrollment period, health zone administrative staff make frequent trips to the health centers to collect the premiums, distribute stamps, and monitor recford-keeping. Each health center is visited 10 to 12 times during this 6 to 8 week period. An example of the control sheet for the sale of membership stamps is attached in Annex IV. According co Moens, the incremental cost of administering the program was 75,242 Z ($586) in 1987, or 4.2% of the premiums collected (14). This amount does not include the cost of salaries of health zone staff who are involved in regular record-keeping and control activities (verification of membership of hospitalized patients), since no additional staff were hired to work full-time on administering the insurance plan. The authors estimate that the full cost of plan administration in 1989 (including the cost of part-time administrative staff) will be 632,015 Z. ($1,784), or 5.7% of the premiums collected. All cases which are seen at the hospital must either be referred by a health center or must pav for a private doctor visit not eligible for insurance coverage. When an insured patient arrives at the hospital, he presents his referral slip. The referral slip indicates the insurance membership number, which is also the number accorded the family during the nealth zone census. If referred, all patients may see the doctor in this manner, before paying any fees. Since referral is mandatory, most cases warrant hospitalization; the doctor then fills out a hospitalization card during the patient's initial encounter, transcribing the insurance membership number from the referral slip. The cashier's office then checks the patient's insurance number against the insurance plan membership register, which was filled out by the health center nurse during the enrollment process. As mentioned earlier, these notebooks are organized by village. If the patient's name appears in the insurance membership register, the patient is charged the insured (Payor Category B) price, generally a 20 percent co-payment. If the name does not appear in the register, then the patient pays one of the other prices, depending on payor category. The cashier clerk writes a receipt, which is stapled to the patient's hospitalization card. Each payor category has a different color or type of receipt. A copy of the receipt rests with the clerk, who then transcribes the information into the cashier's register, a chronological register of all paying hospitalized cases. Three categories of patients pay no fee when they receive care: (I) women delivering babies who are insured and received prenatal care; (2) trypanosomiasis patients who are covered under a special donor program; and (3) school children for whom an annual aggregate payment is paid by the schools. Premiums are deposited in a special fund for the insurance plan, at the CDI. The health zone administrator keeps the financial records regarding deposits, withdrawals and transfers from the fund. Each month, the hospital bills the insurance fund for the services provided to hospitalized patients who are insured. The bill is calculated by multiplying the number of insured patients hospitalized in each service by the unit charge per service, minus the copayment. The hospital administrator also records the amount of interest which the fund accumulates each month. Between 1987 and 1989, interest rates paid by the CDI have ranged from 2.5% (1989) to 3% per month (1987 and 1988). Administrative expenses (bonus payments to staff during enrollment period, transportation expenses, enrollment register-books and stamps) are also subtracted from the fund, although the chart of accounts is not used to record the nature of each expense. At the start of the 1989 accounting year (April 1989), the insurance fund loaned the health zone's pharmacy 7 million Zaires (69% of the fund's balance). In August, the pharmacy repaid 3 million Zaires to the insurance fund. In lieu of interest, at the end of the year the pharmacy 19 administrator (a Belgian nurse) will calculate the benefit to the pharmacy from having purchased drugs early in the year, before the Zaire devaluated further, and will remit this amount to the insurance fund. 3. Resource MAobilization A principal objective in establishing Bwamanda's insurance plan was to improve the financial situation of the reference hospital. Social goals were also incorporated into the design of the plan, notably the decisions to provide 100% coverage of deliveries and to provide coverage of chronic illness treatment at the health center level. This section presents a financial analysis of the relevant policy questions: o Has the insurance plan helped the financial condition of the hospital? o What effect has providing coverage of chronic illness care had on the cost recovery performance of health centers? o Is the insurance plan financially sound? Do the premiums cover the cost of services to beneficiaries, plus administrative costs? How important is revenue from interest? Table A.4 presents the financial statements for the insurance plan from 1987 through 1989. The data show "hat in 1987 and 1988 the insurance plan covered 100% of hospital charges for health care benefits provided to beneficiaries, and covered incremental administrative costs, with positive margins. The plan is projected to cover hospital charges and administrative costs in 1989, as well. Hospital charges are naturally the largest expense category (89% in 1989). Charges for chronic illness cases treated at the health center level account for 6 to 7% of expenses, while administrative costs are 4 to 6%. Table A.5 shows the financial situation of the hospital for 1985 to 1986 and 1988 to 1989. (Data for 1987 were not available). The table shows that cost recovery of the hospital improved with the implementation of the insurance plan between 1985 and 1988. In 1985, the hospital covered approximately 48% of operating costs (excluding depreciation and expatriate salaries) with user charges. This figure jumped to 65% in 1986, and 79% in 1988.6 Using the inflation rates in Annex III, real operating revenue grew by 21% and real operating expenses grew by 70% from 1985 to 1989, the period over which the insurance program was implemented. In 1989, operating revenue is projected to cover only 35% of operating expenses. This figure is suspect, however, because of the complex accounting procedures and co-mingling of funds within the Bwamanda health zone. (The health zone only makes accrual and other adjustments once a year, when preparing year-end financial operating statements. These had not yet been made and were not factored in the projection). The percentage of total expenses allocated to salaries increased from 41% in 1985 to 53% in 6 Depreciation figures are not available for all years, and so were not included in Table A.5. In 1988, depreciation expense was 415,000 Z (S2,219). When depreciation expense is included, cost recovery falls to 76%. 20 Table A.4 FianciaL Situation of Swambnda Insurane Plan, 1987-1989 Current Zaires, with adjustments (see note) 1987 1988 1989 ................ ............. .... ... ,...... .... ....... Current X of Current X of Current X of Zaires Expen. Zeires Expen. Zaires Expen. REVENUE v ................ ................. Premiumi (urwdjusted) 1,785,060 4,023,100 10,177,250 Adjusted* 2,065,314 118.91 4,851,859 101.01 11,011,785 98.6X Interest 460,692 26.5X 935,h75 19.51 710,596 6.41 ADJ. PREh & INTEREST: 2,526,006 145.41 5,787,614 120.51 11,722,381 104.9Z EXPENSES Hospital care 1,671,500 96.21 4,226,055 88.01 9,915.491 88.8X Health center care 0 0.01 346,250 7.21 622,582 5.61 ................ ................ ................. Total care: 1,671,500 96.21 4,572,305 95.2X 10,538,073 94.3X Vehicle; stationary N/A N/A 198,920 1.81 Staff bona payments N/A N/A 338,295 3.01 Administrator (101) N/A N/A 22,800 0.2X Nembership clerk (50X) N/A N/A 72,00F 0.6X ...............- ---------------- ----------------- Total administration: 65,378 3.81 229,885 4.81 632,015 5.71 TOTAL EXPENSES: 1,736.878 100.01 4,802,190 100.01 11,170,088 100.01 .............. .................... .... NOTES: Erpeses and interest in 1989 *re *xtrapolated from 5.5 months of data. ' PremiLm revenue Is received in a Lump su early in the year (on average in March), while expenses are evenly distributed throughout the year. Thus a sLight adjustment is needed within ench year, to assure comparability of nominal Zaires. The prmium revenue has been infleted by the following three-month inflation factors 1987: 1.157 1988: 1.206 1989: 1.082 Exchange rates and inflation rates for each year are fourd in Annex 111. l988.7 If expatriate salaries were included, the hospital's total operating costs would rise by 8% (using salaries of Zairian staff) or 58% (using a conservative estimate of actual salaries). The amount spent on drugs rose from 31% in 1985 to 47% in 1986, then fell again to 30% in 1988. Table A.6 shows the financial situation of Bwamanda's health centers and health posts. In 1988, the year the plan coverage went into effect at the health center level, health centers received 346,250 Z ($1,852) from the insurance plan for services provided to members. This accounted for 3.1% of their total operating revenue. The health centers had a 14.2% profit 7 The value of expatriate salaries has not been included in the financial statements because data are not available from all years. In 1989, the hospital benefitted from the donated services of five expatriate volunteers: three nurses and two doctors. Valued at the salaries of equivalent Zairian staff, this subsidy of in-kind services is worth 4,020,000 Z ($11,349), accounting for a 31% increase in personnel expense, and an 8% increase in overall hospital operating expenses. With the value of expatriate salaries included, personnel expense accounts for about 38% of total expenses. 21 margin in 1988 (excluding depreciation). '.able A.5 Financial Situation of Swoenda Hospital, 19"5-1986, 1988-1969 Nominal Zafres 198s 1986 1988 1989 ...................... *^s ^Zzes ooovo* ** ...................... ................. . . ...................... w* * Nominal Z. X of Expen Nominal Z. X of Expen Nominal Z. X of Expen Nominal Exp. Rev. OPERATING REVENUE --- - -........-------.- .....-.---.-- .--- .- .-.- User fees N/A N/A 873,652 29.8s 2,267,eo8 24.02 3,960,089 12.92 Employer bllitng N/A N/A 394,353 13.4X 2,045,425 21.6X 714,750 2.3X Insurance plen 0 0 650,900 22.22 3,120,905 33.0X 5,204,045 17.02 Other N/A N/A 0 30,600 0.3X 743,925 2.4X .......... ...... .......... ...... ......... ...... ........... ...... TOTAL: 878,583 48.72 1,918,905 65.42 7,464,730 78.9s 10,622,809 34.72 OPERATING EXPENSES Persomel (excl. expats) 739,207 41.02 1,007,462 34.3X 5,036,307 53.2x 9,082,368 29.7x Drugs and med. supplies 563,607 31.22 1,337,286 47.32 2,830,552 29.92 1S,272,868 49.92 Office sI.plies 75,515 4.22 40,093 1.42 204,086 2.22 526,853 1.72 Transport 84,729 4.7X 0 0.02 0 0.02 2,003,736 6.52 Maintenance 176,947 9.82 146,678 5.02 499,619 5.32 1,431,446 4.7X Fuel & electricity 163,839 9.12 276,101 9.42 676,749 7.22 131,813 0.42 Food service & other 0 0.02 76,795 2.6X 212,687 2.22 2,174,505 7.12 ......... ...... ......... ...... ......... ....... ......... ... TOTAL: 1,803,844 100.02 2,934,415 1fl'2.O 9,460,000 100.02 30,623,588 100.02 OPERATING SUBSIDIES: 925,261 51.32 11015.510 34.62 1,995,270 21.1X 20,000,779 65.32 NOTE: 1989 figures are extrapolated frm 8 months of data. Table A.6 Financiat Situation of Health Centors in S_amenda, 1985-1986, 1988-1989 Nominal Zaires 1965 1986 1988 1989 Nominal 2. X of Expen. Nominal Z. X of Expen. Nominal Z. 2 of Expen. X of Expen. PERATING REVENUE -------------- .. .. User fees 1,312,131 106.52 2,283,794 109.22 12,393,789 111.1 19,231,628 92.52 surance plan 0 0.02 0 0.02 346,250 3.1% 993,873 4.82 TOTAL: 1,312,131 106.52 2,283,794 109.2x 12,740.039 114.22 20,225,501 97.22 PERATING EXPENSES Personrwel (excl.expets.) 476,244 38.6x 649,670 31.1X 2,93,758 26.72 6,537,590 31.42 Drugs and med. 4uplIes 521,298 42.32 1,197,702 57.32 6,899,327 61.82 10,932,372 S2.62 Office supplies/mint. 126,405 10.32 243,342 11.6" 1,283,712 11.52 1.888,631 9.12 supervision fe 1t08,600 8.82 0 0.02 0 0.02 1,040,469 5.02 Hosp. prenatal services 0 0.02 0 0.02 0 0.02 402,442 1.92 TOTAL: 1,232,547 100.0o 2,090,714 100.02 11.156,797 100.02 20,801,503 100.02 'ROFIT (DEFICIT): 79,s54 6.s5 193,080 9.22 1,583,242 14.2X (576,003) -2.82 NOTES: 1989 figures are extrapolated frm 8 months of data. Cost recovery in Bwamanda's health centers was high even before the plan went into effect: in 1985, the health centers had a profit margin of 6.5 percent, excluding depreciation. In 1986, 22 cost recovery was even better, with a 9.2% profit margin, although the financial records show that the zone did not charge the health centers for supervision costs in 1986 and 1988. Hospital costs in the Bwamanda health zone are similar to those of other well functioning zones. Of the eight zones for which Bitran et al compiled per capita hospital expenditures in 1985, Bwamanda ranked third lowest (4). It3 per capita cost was $0.42 (21 Z) compared to the eight-zone average of $0.65 (32 Z). 4. Utilization and Access to Services Theories of insurance suggest that insured persons may use more services than uninsured due to both adverse selection (the tendency of persons more likely to need services to purchase insurance) and moral hazard (the tendency of persons to be more prolifigate in demanding services when they face few financial penalties). These phenomena make the development of insurance more difficult because they raise premiums, further discouraging health, low cost people from buying insurance. The authors examined whether these theories applied to Bwamanda and confirmed that they did. The authors' analysis of utilization data showed that distance and membership status strongly affect hospital utilization. Hospitalization rates are higher for members and workers with employer-provided health care coverage than for Bwamanda residents who have no form of health insurance or employer coverage. The authors examined this pattern with two sets of data: monthly utilization statistics tabulated by each service, and a ten percent sample of entries from the hospital register for all admissions. Table A.7 compares the insurance status of hospitalized patients with the insurance status of Zaire's population. While 77% of the patients are insured, only 60% of the health zone population are members of the insurance plan. Persons covered by an employer are even more overrepresented among the patients than in the population. There are three times more employed persons, and only a third as many uninsured patients hospitalized than expected from their frequency in the population. Table A.7 Distribution of Payment Categories in the Population wnd Hospital Patients, Dec.1988 - Oct.1989 (maternity patients exctuded) POPULATION HOSPITAL PATIENTS PAYMENT FROM ZONE* CATEGORY PERSONS X SAMPLE X Eaployed 6,176 4.61 54 17.3X Insured 81,142 60.2X 240 76.7X Total not Insured 47,362 35.2X 19 6.1X TOTAL 134,680 100.0l 313 100.01 * Th. original smple of 329 patients Included 16(4.9X) from outside of Bwmwds zone. They were removed fro the onot insuredO category, Leaving the 313 petients reported here. 8 These were derived by dividing the total expenditures for hospitals in the zone by the zone's population. This calculation does not adjust for net border crossing. 23 The systematic one in ten sample of patients from the admissions register covered patients admitted from December 1988 through October 1989. Data were analyzed according to four major service categories: pediatrics, internal medicine, gynecology and surgery. Obstetrical patients were excluded because of incomplete records. Based on the hospital register, Table A.8 shows that the annual hospitalization rate was 10.5% for salaried workers and family members with employer-paid health coverage; 3.6% for members of the Bwamanda insurance plan; and 0.5% for Bwamanda residents without insurance or employer coverage. Table A.8 1989 Acdmission Rates by Payment Category -----Payment Category----- Over- Not TOTAL all Service Insured Insured Employed ZONE Total (Population) 47,362 81,142 6,176 134,680 n.a.** Arnual Admissions:* Surgery 166 547 71 788 840 Gynecology 29 132 26 276 283 ALL (Exc.Obs.) 231 2,640 594 3,465 3,330 Arv.uAl Admission Rates X): Surgery 0.35X 0.67X 1.15X 0.59X Gynecology 0.06X 0.16X 0.43X 0.20C ALL (Exc.Obs.) 0.49X 3.25X 9.62X 2.57X Risk Ratios for Admissions: Surgery 1.0 1.9 3.3 1.7 Gynecology 1.0 2.7 7.0 3.4 ALL (Exc.Obs.) 1.0 6.7 19.7 5.3 .. .... .... .. .... ...... ............ ....... ..... NOTES: * Mutbers of surgery and gynecology adtissions were extrapolated from complete utilization statistics from January through June, 1989 by doublIng the six-month total. Numbers of arusal ecmissions for all services (excluding obstetrics) were extrapolated from a 10X satpte of such admissions from December 1988 through October 1989 by multiplying the total by 12/11. The extrapotations were based on 657 wurgical a*dissions, 230 gynecology wdnissions, nd 329 total non-obstetricat admissions, respectivety. * Overalt a*Issions lnctude admisslons of patients from outsid, of the Swawand hea'th zone. The risk ratio for a payment category is the ratio of the admission rate for that category relative to the rate for uninsured persons. The risk ratios across these services show consistent patterns. Insured patients had from 1.9 to 6.7 times the admission rates of uninsured patients. Employed patients had dramatically higher admission rates: 3.3 to 19.7 times those of uninsured patients. This pattern of higher rates for insured and employed persons, compared to uninsured, is probably the combined effect of moral hazard, some adverse selection, better access, (closer residents were more likely to be insured) lack of adequate controls (which may permit non- members to falsely present themselves at the hospital as members) and random variation due to small numbers. Table A9, based on the survey, provides further support of adverse selection and/or moral hazard. 24 Table A.9 Survey of HospitaLized Patients in Bwamanda . .............................................. ........... ..................... ........................... Insured Uninsured (N229) (M221) Stat. Characteristic Mean STO Mean STD Sig. ........................................... .............................................................. .............. Age in years 20 19 22 20 Payment for current hospitalization in Zaire 1568 1700 4083 4070 - Number of episodes of serious ilLness 2.4 2.9 1.6 1.2 In househoid during 1988 and 1989 Nutber of hospitalization episodes in.househotd during 1988 and 1989 2.6 4.4 1.7 1.2 Nuiber of times the patient was hospitalized from 1985 thru 1989 2.8 2.7 1.3 1.8 - Number of persons in househoLd: Children 5.5 6.7 5.6 3.1 Younger aduLts 3.8 3.5 2.7 1.2 Elders 0.7 1.1 0.6 0.7 TOTAL 10.0 8.4 8.9 3.3 For employed persons, both the hospital and the patient have every incentive to hospitalize. Care is free to the employee, and the hospital is paid two to three times the fee of a self- paying patient. The problem of higher hospital use by insured patients has not had a serious effect on the financial solvency of the insurance plan, since the plan covers such a large percentage of the population (60%). With lower enrollment, such a problem could bankrupt an insurance system. The fact that insured patients use only a third to a half as much hospital care as employed persons suggests that the 20% copayment may have limited moral hazard. Principles of medical geography suggest that people will consume more health services the nearer they live to the site of care. By examining the pattern, one can see whether the data on utilization rates are plausible. Further, by examining utilization for both distance and insurance status, simultaneous possible confounding between these variables can be eliminated. The figure shows that insured patients used more services, regardless of distance. A similar pattern held for internal medicine admissions (one third of all admissions), separately. Overall hospital admission rates for all services (excluding obstetrics) were also examined by distance for 1989. Figure A.2 shows the regression of admissions for all payment categories and admissions with insurance coverage on distance from the hospital. The 21 observations are villages covered by Bwamanda Hospital. There was no evidence of any meaningful difference in delay between insured and uninsured patients. A patient going to Bwamanda Hospital knows that he must pay on or near admission. As an uninsured patient faces higher fees, it may take him longer to assemble the necessary cash. Using data from Kombo, Bombisa, and Dondeme Health Centers, the authors found minimal delay among both insured and uninsured patients in both groups. In previous work, Moens had examined whether patients actually followed up on referrals to the hospital. He found that rates were high and comparable for both insured and uninsured patients. 25 HOSPITALIZATION RATE FOR ALL PATIENTS Ey DISTAN. PE 1000 PPU..ATI0N so - 50 40 c 30- 20- 10 -10 0 20 49 6'1o DISTANCE IN 1)J + rarAL ADMISSIONS v INSLwM I WissIONS Figure A.2 The study team examined a number of other indicators of quality for differences between iniured and uninsured persons: - Proportion of high risk pregnancies delivered in hospital - Proportion of all deliveries in hospitals - Age adjusted overall death rate overall - Childhood death rate Proportion of pregnant women enrolled in ante-natal care - Birth rate - Length of hospital stay. - Delay in starting delivery. The study team tested most of these indicators with a visit to Isabe health center, one of the health centers served by Bwamanda Hospital. In theory, the data to calculate most of these indicators should have been available at the health center through the family registration cards; the remaining data should have been available at the hospital. In practice, the data proved inadequate because family cards did not necessarily record every birth and death, particularly if they occurred at home or in the hospital. For example the Isable household cards in Isable showed 876 people. The cards reported only 21 births (about half the expected number) and 8 deaths (also fewer than expected). Table A.10 presents comments of insured and uninsured patients towards possible changes in 26 insurance. Members (n-29) indicated their benefits and disadvantages. Non-members (n-21) indicated why they did not join. Members were interested in seeing ambulatory care covered at a modest increase in premium. Those not joining had diverse reasons, including living outside the catchment area. Table A.10 Swamwda Survey: Attitudes ..... ............. ........................................... No. of Survey question X Respond. Can you increase your premium from 125 26 to 200 Zaire to cover nmbulatory care? Yes 80.8X No 19.2Z why did you decide to be a meber? Cheapest way to get care 89.72 29 Quality of care is better 3.4X solidarity 3.4X I thought it was oblieatory 3.42 Other 3.4X What benefits do you receive from your membership? The personnel sees me faster 37.0X 27 I have better health 3.72 i want to support the institution 3.72 Quality of care is better 22.22 Other 3.7X No response 29.6X What are the disadvantages or problem of insurance scheme? Too expensive 6.9X 29 It is necessary to come for ftollow up 17.2X visits No response 75.92 Why are you not a member of the insurance scheme? I have no money 16.02 21 I didn't know at the time of 5.02 Other 75.0O 27 B. CASE STUDY OF BOKORO The rural health zone of Bokoro, located in the Bandundu region of Zaire about 350 km north- east of Kinshasa, was created in 1981. Services at health centers and hospitals are coordinated by a central office (Bureau Central de la Zone de Sante, BCZS). The various organizations which provide health care in the zone are represented in the zone health committee: the government, the Catholic and Baptist missions, the Belgian Cooperation, etc. The zone recovers a substantial part (over 80% in 1988) of its recurrent costs including local salaries through fees for services. Certain services receive technical and financial assistance from a variety of sources to close the gap between the available budget and expenditures. The referral hospital Bokoro recovers over 60% of its costs through fees for services. In contrast to the Bwamanda health zone, the referral hospital in Bokoro does not enjoy a monopoly position. It faces several officially recognized and some 'illegal" competitors for inpatient care. The hospital has made considerable efforts since its creation to improve access to ambulatory inpatient care all over the zone. As a result, occupancy rates in the Bokoro hospital have decreased drastically since the late 1970's. When the rate stabilized in 1987 at about 1200 admissions per year excluding the maternity, it was about half the level of 1978. The number of available hospital beds decreased simultaneously, from 127 in 1986 to 78 in 1989, resulting in an annual occupancy rate of 40% to 45%. The average length of stay is about 10 days. In addition to the inpatient care, the hospital provides ambulatory care to 1,500 to 2,000 patients every year amounting to about 5% of its annual operating expenses in 1988. 1. Terms of the Insurance Plan The Bokoro subscription plan is a direct insurance plan, offered by the provider, the Bokoro Rural Health Zone. Since its introduction in 1985 the insurance plan, called the "abonnement," has undergone dramatic changes. Originally intended to guarantee comprehensive care, including preventive, ambulatory and inpatient care at the peripheral and referral level, today this plan covers only curative ambulatory care. Due to financial difficulties, extra charges are imposed for chronic diseases like diabetes and hypertension. Preventive care, family planning, deliveries, prolonged treatment, treatment of sexually transmitted diseases and antibiotics and injections are not included in the insurance plan; patients must pay for these. First line treatments of tuberculosis and leprosy are provided free of charge through separate programs. Table B.l shows the full charge schedule at the health center. Insured patients pay 25 percent of these charges; uninsured patients pay the full amount. There is no cap on spending. As virtually all enrollees are employees, any cap would be inconsistent with the Zaire employment laws, which require employers to pay for all medical care. Most employers in the zone, including health services, missions, and processors of agricultural products (such as BIMPE) enrolled their workers and dependents in this plan. Presently over 4,000 persons are covered, representing 4.5% of the Bokoro Health Zone. Enrollment in the .nsurance plan (abonnement") costs 1,200 Z per person per year. When one family member enrolls, the entire family is obliged to subscribe. This requirement reduces the likelihood of an adverse selection as well as sharing one card among family members. Contributions for an entire family can easily reach 12,000 Z. This premium is very expensive for the general population; thus, the enrollment rate outside of employees is presently close to nil. No co-payment was associated with the plan initially. To reduce the moral hazard patients must now make a 25% co-payment of the normal non-subscriber fees. Because only employees are enrolled and they should be reimbursed for this copayment, this policy should not affect 28 Table 8.1 Fees for Service at Health Centers Bokoro Health Zone, 1989 ............................................. SERVICE CATEGORY IZAIRES ..................................... ................................ . CONSLILTATIONS Children, registered at NCH 120 Children, not registered 150 Patient above 14 years 180 Patient from outside zone 250 MATERNAL and CHILC HEALTH Pre-school care inct. immdization (5 yrs.) 200 Ante natal care (9 months *) 200 Planrnd parenthood (12 months) 300 F) for one disease episode up to 5 days duration. Extra charges apply for: antibiotics, drugs after the fifth day, fee for after hour consultations. ') Excluded: weekly malari prevention. utilization substantially. From the survey, it was not clear whether insured respondents were actually reimbursed for all medical costs. Services are fully available to uninsured persons upon payment of a flat fee for an episode of care. A minimum charge was set at 180 Z for an adult in 1988 by the BCZS. However, the health committee for a health center can decide to charge more, for example 500 Z. Services covered by the flat rate are limited. Extra charges arise for antibiotics, prenatal and child care. To better characterize the insured and uninsured population and to assess interest in other forms of insurance, a small survey was conducted. The questionnaire was similar, though not identical, to the one used in Bwamanda, discussed above. The questionnaire was written in Lingala. Annex V contains a copy of a completed questionnaire in Lingala and an English translation. Of the 47 subjects interviewed, 21 were a systematic one-third sample of the 63 non-maternity inpatients in Bokoro Hospital, and 26 were heads of families (all farmers and fishermen) from the towns of Bokoro and Kempa, 12 km outside Bokoro. These 26 families were chosen systematically from family cards in the health centers of Bokoro and Kempa. Table B.2 characterizes the insured and uninsured respondents. Table 5.2 Bokoro Survey: Population Characteristics. Insured Unirnsured Valid Characteristic (Nu21) WMZ6) Responses ......... ....................................... Gender: Fm_ le 29X 46X 47 Male 11 S4X Average Age 35 32 47 SDO f Age 14 20 29 *Patients from: 47 Sokoro Hospital 38J 50X 21 lokoro Town 33X 23X 13 Keop Toin 29X 272 13 Receives a slary each month 19X 8X 47 Occupation: 47 Agricutture/CuLtivation 572 65X Fishing 102 82 Teacher 14X 02 Driver 02 4X ELptoyed (details unspecified) 5 8X Trader 102 42 No occupation or no response 52 122 Eptpoyer: 47 Pere-stataL enterprise 52 OX None or no response 952 1002 Would you be able to pay in cash 10,000 Zaires 47 for an illness requiring minor surgery in a hospitaL? Ues 192 4X No 762 e8l No response 5S 8J ,........................................................... ......................... * Percentage of respondents from each source Insured: Bokoro HospitaL, 382; Sokoro town, 542; Keqsa tow, 462. 2. Organization and Management Three major concerns led to the introduction of an insurance plan in 1985 by the health zone authorities: a) the financial accessibility to health care was too limited for the majority of the population of the zone; b) a referral to the hospital was a severe financial burden; and c) revenues were not able to cover most recurrent costs. The level of the premium is based on historic utilization rates, an average length of an episode and the quantity of drugs and materials consumed. The utilization pattern of a group of private employees (BIMPE corporation) was initially used as a standard. The premium was set to 600 Z in 1985 and remained constant until April 1989. In that month, the rate was doubled to 1,200 Z. Actual utilization in 1989 was found to be two consultations per member per year and the average cost was 500 Z per consultation. In April 1989, the annual premium was doubled to 1200 Z. The increase anticipated continuing inflation (which sometime exceeded 100% per year), and a possible increase in utilization. Insurance premia are paid to the provider, the health center. Premia for employed persons and their dependents are paid by the employer. In theory, people could enroll at any time during the year. In practice, enrollment tended to be highest after the two harvest and fishing seasons in this area, January, July and August, when the agribusinesses had the most cash and were best able to pay the annual premia for employees. The names of all insured family members are recorded on duplicate forms. One copy remains at the health center and the other with the family. No unique identification numbers were used for each subscriber. The study team found no controls that would prevent non-enrolled persons from borrowing an insured person's enrollment form. It was not possible to assess the extent to which free care was provided to unregistered persons or persons where the 30 membership had expired. Although the Bokoro subscription plan does not cover inpatient care, it indirectly pays for the initial hospital consultation. Prior to admission the patient pays a consultation fee for the physician visit. About two thirds of the outpatients are referred by the health centers. For each referred outpatient, the hospital charges the referring health center 300 Z, thereby generating about 300,000 Z. Rcferred patients themselves pay nothing for this consultation, but they do pay regular hospitalization charges if they are admitted. Self-referred patients pay 500 Z for their outpatient consultation. The system of referral accounts for health centers was introduced in 1985. These accounts were intended to pay for hospital care of patients referred from the health center for continued treatment of the same illness episode. Due to limited revenues, however, only outpatient consultations at the hospital are included today. Fifty percent of the health centers' profit (the balance of revenues after deduction of recurrent expenses and costs of drugs) is credited every month to the referral account. This system of referral accounts, similar to one used in the town of Kasongo, was intended to provide a form of risk pooling. Minor outpatient episodes would have subsidized more costly problems requiring hospitalization. Kasongo reportedly has had similar problems to Bokoro, however. At the level of flat fees for outpatient care that are acceptable, it is not possible to generate sufficient revenues to finance inpatient care. All revenues after deduction of local exoenses are transferred monthly to the central account of the health zone at the Service a' Approvisionnement en Fournitures, Equipements et Medicaments (SAFEM), which keeps separate accounts for the hospital, zone, and pharmacy. At the BCZS each health center has its own account showing debits and credits. Funds generated by the insurance plan are not separated from other revenues. As a result, it was nut be possible to estimate the administrative effort for the plan separately. 3. Resource Mobilization The health zone as a whole operated at a deficit each year from 1986 through 1989. In 1988, the deficit was 2 million Z. The majority of health centers either have deficits or generate insufficient profits to cover the administrative costs of the BCZS. There is a severe disincentive for these health centers to function well. If they make a profit, only 15% is retained for investments and only 10% for discretionary use by the health committee. Moreover, there is no punishment for bad performance; rather the good centers will have to share the entire burden. Preserving premium income over the year is a problem throughout Zaire. Savings kept in cash is eroded by inflation, and bank interest rates are generally far below inflation. The study team identified several institutions in which revenues from the health insurance plan could be invested. Last year a rural savings cooperative, Societe Cooperative d'Epargne et de Credit de Bokoro (SECREB) was created by private citizens. A very competitive interest rate will be paid this year for short term (several months) deposits. An alternative is several private merchants who supply farmers with tools and material and who buy their products. Several of them are seen by long time Bokoro residents as serious partners for investments. Before examining the financial status of Bokoro hospital, its charge structure will be reviewed. An advance of 2,500 Z has to be paid on admission. This amount covers an anticipated period of hospitalization of 10 days; the minimum charge is for five days (1250 Z). Any unused balance is refunded to the patient. In addition the patient pays for various procedures and for certain drugs. Table B.3 shows a detailed price list for services provided at Bokoro Hospital. 31 Table 9.3 Fees for Service at Bokoro Hospital, 1989 SERVICE CATEGORY I ZAIRES SERVICE CATEGORY I ZAIRES AMBULATORY CARE INPATIENT CARE Consultation, referred 300 Deposit 2,500 Cons. non-referred 500 Niniam Payment 1,250 Cons. nurse on duty 200 Any additional day 250 Outpatient care * 1 week 500 Diabetes (6 months) 250 Private room per day, standard 500 Private consultation 1,000 Private room per day, Luxury 650 Nedical certificate 500 Laboratory, cat. 4 250 Surgery, cat. 1 2,100 Laboratory, cat. 1 50 Surgor), cat. 2 3,150 Laboratory, cat. 2 100 Surgery, cat. 3 4,050 Laboratory, cat. 3 150 Surgery, cat. 4 4,850 Laboratory, cat. 4 250 Surgery, cat. 5 7,200 Surgery, cat. 6 8,650 X-Ray 1,000 Spinal anesthesia A50 Ultrasound, extern, w/ med.need 1,000 Ultrasound 500 Ulttasound, extern, on demnd 2,000 X-Ray 1,000 Echocardiogram 350 Surgery, cat. 1 1,250 Eye examination 250 ............................. ...................................... ..... e.... Table S.4 Firnncial Situation of Bokoro Hospital, 1986 - 1989 Percent Percent Percent I Percent of total of total t of total I 1.HALF of total 1986 exenses 1987 * ees 1988 exeses I M989 expenses ------------- ------.. ----- ------------------1- ----------------------1----------------------- Exp. Rev. |Exp. Rev. | Exp. Rev. Exp. Rev. OPEiRATING REVENUE User fees and I I I I I I I insurance plan 2,218,013 91.7X13,189,941 1 99.3115,220,314 1 96.91I4,147,044 1 98.3X Others 201,598 i 8.3X1 21,398 | 0.7%1 164,501 i 3.1X1 71,782 | 1.7X ------.---I ... .. .---------- --- ..I ----- 1--I----- --- -- TOTAL: 2,419,611 | 96.7813,211,339 56.3X15,384,815 16.3X14,218,826 | 62.1X OPERATING EXPENSES I I I I I I Persorrel (excl.expats) 846,222 I 49.61 12,049,358 I 52.81 12,768,706 46.4% 12,932,384 1 44.5X Drugs and med.supplies 404,718 23.71X, 990,890 1 25.51 12,322,755 I 38.9X 12,834,017 1 43.01 Office siplies 16,220 1.01 I 29,483 I 0.8X 39,113 I 0.71 I 78,296 I 1.2X Tranrport 610 | 0.0% % 96,548 | 2.51 | 141,861 | 2.41 | 31,334 | 0.5X Maintenance 61,403 3.61 I 105,648 2.7S 126,212 2.1X I 127,772 1.9X Fuel £ electricity 216,910 12,71 I 4,757 11.5X 429,037 7.2x 55S,316 I 8.4X Food service & other 159,499 | 9.41 | 166,234| 4.2 | 140,943 2.4X | 34,282 | 0.51 .---.- ------ 1 .-------1- ----- --.-.-.-- - ---------- ----- TOTAL: 1,705,582 |lOO.0 13.8a0.918 |100.01 O5,968,627 1100.01 16,593,401 1100.0| OPERATING SUBSIDIES: 33,099 | 1.3112,497,14 1 43.7X12,742,143 | 33.7112,574,322 | 37.91 I --- 1 1 ---- 1 ---I ... 100.0O1 I 100.0O1 I 100.0X1 I 100.0l 32 Table B.4 shows the cash flow of Bokoro Hospital from 1986 through the first six months of 1989. Revenues from operations together with subsidies cover hospital expenses every year. While in 1986 almost 99% of operating expenses came from operating revenues, this share dropped to 56% the following year. In 1988 and 1989, respectively, 34% and 38% of operating expenses are covered from subsidies. The Catholic mission, the Belgian Cooperation, SANRU, FONAMES, and the government of Zaire contributes salaries for some of the personnel. The share of expenses for drugs and medical supplies has doubled over the past four years and is approaching 50% of the hospital's recurrent costs. It was not possible to distinguish between revenues from insurance funds and direct patient charges. The hospital budget is shown to cnable a calculation of necessary revenues from a hypothetical insurance for hospital care. Given the present subsidies and the present level of services the hospital would need a minimum of 40,000 subscribers. Including anticipated administrative costs for the insurance plan and an inflation rate of 60%, a premium of 200 Z per person would seem necessary. 4. Utilization and Access Rates of utilization of ambulatory care services at the Bokoro Health Center for the first six months in 1989 are shown in Table B.5. D.fferences in utilization between subscribers and the uninsured are striking. Based on the six months average, subscribers consult five times as often as non-subscribers with a new disease. Rates of treatment with antibiotics, antibiotic prescriptions, and injections show a similar pattern. Subscribers use two to nine times as many services. Their higher utilization rate is not necessarily due to insurance, however. Every plan subscriber is employed and all medical expenses for the family are covered anyway. In the household survey, mentioned earlier, respondents were asked about their preferences regarding health insurance. A single annual payment of 100 Z to 200 Z per family member seemed affordable. The preferred times to pay were January, July, and August. The survey of members showed that they were interested in broader coverage that would include hospital care as well as ambulatory care (see Table B.6). While hospitalized patients naturally preferred hospital care, a majority of healthy villagers preferred ambulatory care. A major handicap to wider enrollment is probably the lack of an incentive for the health personnel to attract new subscribers. The staff of health centers are evaluated and rewarded with an incentive payment for an overall high utilization rate, correct operational procedures and having more revenues than expenses. No incentive is provided for new plan subscribers. These would merely add to the work load but not necessarily increase the profit. Health zone administrators complained that clinical personnel did not believe in the value of the insurance scheme. Thus, their publicity and educational efforts were minimal or even negative. No clear policy had been formulated regarding the best enrollment period. The authors felt that if the premium were lower, substantially more subscribers would enroll and would dilute the present high risk membership with more low risk subscribers. The health committee members and health center staff with whom they spoke, however, could not follow t;.is argument. The study team felt that respected community institutions could assist in publicizing the idea of a prepayment plan. In Bokoro, the Programme des Actions Complementaires (PAC) might serve this role. It was created to promote social services, agricultural and fishing activities and 4% associated with the BCZS. Also, two religious missions (Catholic and Baptist) have contributed greatly to the development of the Bokoro area over the past 70 years. They enjoy great confidence of the population which could be an important factor for a successful 33 Table 6.5 Health Care Utilization by 'lan Subscribers nd Non-subscribers at Bokoro Health Center * I 1989 Jan Feb Par Apr May Jun | AVERAGE RAThO#I lPopulatfon sze I Non-subscribers 3817 3797 3794 3819 3799 2966 | 3669 | Subscribers I 156 176 179 174 174 176 173 Totat 3973 3973 3973 3993 3973 3162 I 3841 ----------- ----------------- --- ---- -- ------ --------- --1------1 - ----- | | ANNUAL UTILIZATION RATE. Now cases Non-subscribers I 0.45 0.38 0.46 0.48 0.46 0.59 0.47 Subscribers 4.59 1.69 1.86 2.25 1.79 2.30 I 2.36 I 5.0 tAntibiotic prescr.18 Non-subscribers 1 0.03 0.05 0.05 0.08 0.07 0.06 0.06 Subscribers 1 0.49 0.31 0.27 0.31 0.49 0.72 0.44 I 7.3 linjections I I Non-subscribers I 0.14 0.08 0.15 0.32 0.33 0.19 | 0.20 | Subscribers I 1.98 0.92 0.27 1.24 1.51 3.11 I 1.72 8 8.6 AVERAGE RATE PER NEW CASE fAntibiotic Rx I Non-subscribers I 0.06 0.06 0.06 0.09 0.09 0.10 | 0.07 Subscribers 0.11 0.18 0.14 0.14 0.20 0.31 j 0.18 I 2.61 lInjections I I I I Non-subscribers I 0.32 0.21 0.31 0.66 0.70 0.33 I 0.42 I I Subscribers 0.43 0.55 0.62 0.55 0.84 1.35 ! 0.73 ! 1.7 *) Data from the *BORDEREAU DE CONTROLE DE CAISSEn pert A, Nber 14 - 16 wnd 19. ?) Ratio of average for subscribers divided by average for non-subscribers. *) Projected annual utiLization rates, calcuLated as: nimber of services in month * 12 / population size. insurance plan. Table B.6 Sokoro Survey: Ouestions Asked Separately of Insured Respondents (N=21) QUESTIONS Respondents Can you pay 100 Zeares for an in urance scheme 21 which wfil take care of all of your fmily? Wien? Now 52X In a week 19X In a month 10X kewer 19X Can you pay 200 Zaires for an Insurance scheme _ich wIll take care of all of your fteily? 21 Now 38X In one day 5X In a week 10X In a month 29X Never or no response 19X 34 When wilt you like to pay this amount7 17 Any time 41K Dry season (3rd quarter) 41X After harvest (end of 3rd, begin. 4 24X 3rd, 4th or 1st quarter 18X Why will you like to pay dt that time? 17 Enptoyer covered 24X Cash availeble 18X Selling the harvest 12X Selling fish 29X Selling coffee 18X SeLting products 12Z Selling fish and coffee 6X Selling coffee and harvest 6X If this insurance woulo cover either the cost of care at the hospital or at the hospital, 21 Which would you prefer? Health center 33X Hospital 57X 1 don't know 10l Were you sick last month and sought care? 21 Yes, sought care at heaLth center 14K Yes, sought care at hospital 19X No answer or did not sought care 67K 35 C. CASE STUDY OF ST. ALPHONSE The St. Alphonse Health Center is the first and only operating health facility in the urban health zone of Matete, Kinshasa. Since the Matete Health Zone is not yet functional, St. Alphonse is supervised by the Kisenso Urban Health Zone. The Kisenso zone receives technical assistance, capital and operating subsidies from the Belgian-sponsored project 'Sante Pour Tous Kinshasa" (SPTK). St. Alphonse Health Center began operation in 1987, largely through community action channeled through the Development Commission of the St. Alphonse Parish. The health center received investment subsidies from many donors, including the OXFAM Project (Great Britain), the Canadian and German Embassies, and SPTK. At present, the health center is self-financing with a large profit margin. 1. Terms of the Insurance Plan The St. Alphonse insurance plan covers ambulatory curative care episodes of illness at the St. Alphonse Health Center. Plan members are entitled to pay a fixed fee for each episode of illness up to five days, rather than paying for each day of treatment as non-members are required to do. Table C.l lists the prices according to payor category (member vs. non-member). An episode of illness includes up to five consultations and all basic drugs required. Per visit fees also include consultation and basic drugs, but for one day of care only. For both payor categories, laboratory exams are charged separately. Drugs which are not usually kept in stock at the health center level (for example, quinine for chloroquine-resistant malaria) are charged separately as well. Table C.1 Prices, St. Alphonse Health Center Kinshasa, 1987-1989 ZAIRES ............................................................. ADULT I CHILD l 1 ------------- ----------1--------------------------- l l OIN0N-NEN1NiON-ENBI I NON-MENSINON..-ON1 ------- IEMBER |MEMBER IFIRST IOTHER INENSER IFIRST |OTHER I IDATE IPREK!UNIEPISODEIVISIT |VISITS IEPIS XE|VISIT IVISITS I I------- I----- I--------I--------I---1-----I---1---- I--1---- ---1-- -----1I IJAN. 871 50 1 100 I 110 1 50 1 80 (*) I (C) I IJAN. 88l 150 1 150 1 150 I S0 I 100 1 100 1 50 1 IJAN. 891 150 1 300 1 200 1 50 1 300 1 200 1 SO I INAR 89I 300I 5001 400 1 150 1 500 400 1 150 I .................................................................... C') No price was estebltihed for non-nember children the first year. In 1989 differential pricing for adult/children was bwndoned in favor of one price for slt age groups. The health center also offers prenatal consultations and well-baby care; however these services are not covered by the insurance plan. Deliveries are referred to other facilities, although the health center would like to open a maternity service in the future. The population eligible- to join the insurance plan includes the approximately 10,000 residents of the health center's catchment area. No census has been carried out, nor is one planned in the near future. Enrollment in the insurance plan is voluntary. Since the health center opened in February 1987, 1,689 residents have joined the insurance plan, although only about 620 (6.2%) are currently covered under the plan. 36 According to a member of the St. Alphonse Development Commission, many residents in the catchment area are salaried workers with employer health coverage. St. Alphonse health center does not bill employers for care, so there is no record of the number of patients who may not have joined the insurance plan because they are already covered by their employer. The insurance premium for 1989 was set in March, at 300 Z ($0.85) per person. The 1988 premium price was 150 Z ($0.80), increased from the initial price of 50 Z ($0.39) in 1987. In early planning meetings, community members expressed a preference for family enrollment, but the health center staff and development commission members felt that without a census such a system was open to abuse. All individuals pay the same premium. As discussed above, the insurance plan has a co-payment of 500 Z ($1.41) per episode of illness. The insurance plan has not established any deductibles. In 1987 and 1988, the co-payment differed according to age, with a lower co-payment paid by children. All SPTK-supported health zones abandoned this practice in 1989, in favor of a single co-payment. Table C.l shows co-payments from past periods. The episode of illness covered is restricted to five days, and does not cover expensive, special drugs. The health center treats patients who are not members of the insurance plan; in fact, almost 85% of new cases seen at the health center in 1988 were in non-members (see Table C.2 for utilization figures). Non-members do not qualify for the episode of illness price, but are required to pay for each day of care. Currently non-members pay 400 Z ($1.13) for the first day of care, and 150 Z ($0.42) for each subsequent day of care. The average number of visits per episode of illness for non-members thus far in 1989 was 3.6, or an average cost per episode of 790 Z ($2.23) [(I visit x 400 Z) + (2.6 visits x 150 Z)]. As with members, while consultations and basic drugs are included in the price, laboratory exams and special drugs are charged separately. Table C.2 Utilizatiln, St. Alphonse Health Centar Kinshasa, 1968-1989 ........................ ...................................... ............ 1968 1 1989 ----- ------------------ -1----------- ----- ------1 1X IX I number 1 I I umber Itotal irew I (8 mo.) Itotal Inew I I -utI. Icas&$ I (*) lutil Icses I I----- ---1--I--1---- I------ I-----1--- I---1-------1I Members episodes 1 1,413 1 5.2X1 13.7X1 434 1 3.011 10.3X1 hon-members first visit I 8, 8981 32.6X1 86.3X1 3,788 1 26.4X1 89.7X1 Mon-m'rbers other visits(+)I 16,477 1 60.3X1 - 9,710 1 67.861 --- I CPH new cases enrolled 376 1 1.4Z% - 302 j 2.1X1 --- I CPS rew cases enrolted 168 0.6O 1 -- 98 1 0.7X1 --- I ....... .... I ---1----I-1-- -------1I------I------1I TOTAL: |27332 |100.OX1iO0.OX| 14.332 1100. 01100.0%1 1-------------- ------- -1- ------------ ---------1 Visits per episode I I (nomrebs) I 2.9 1 3.6 l ................................................. * Jan. to Sept., *xcltud1n Aprlt (no deta avalt. for April) * Follow-up visits are calculated by dividing total receipts for follow-up visits by priee per follow-up visit. 37 2. Organization and Management The insurance plan began with the ope-1ing of the health center, in February 1987. The Development Commission of St. Alphonse parish was instrumental in creating the health center and mounting an awareness campaign amnng the population in the health center's catchment area. The Development Commission has been in existence for over 10 years, and manages a diverse range of activities in addition to the health center, including a food cooperative, tie-dying cooperative, and an adult literacy program. The health insurance plan-awareness campaign took a full year and involved considerable effort. Four members of the Development Commission worked full-timc for two months, conducting door-to-door vi;its to explain the purpose of the insurance plan. They were assisted by six students from the National Art Institute who were enrolled in the Institute's program in 'animation culturelle.' The students worked full-time for three months. In spite of this concentrated effort, most residents were not convinced about the benefits of joining an insurance plan. The plan bcgan with only 50 members. The St. Alphonse insurance plan is a direct insurance plan, offered by the provider, which is both the center and the zone. Accounting for the insurance plan is mingled with that of the health center. The price of the premium is set by SPTK/health zone central office staff. It was not possible to meet with these people, so little is known about how the premium price is established. Individuals may join the plan at any time during the year, with coverage starting immediately and lasting one year from the time of enrollment. The only restriction is that people cannot join the plan while they are sick. Enrollees receive a membership card which specifies name, age, sex, membership number, date joined, and date of expiration. The health center nurse also records information about each enrollee in a membership register. This register records membership number, date (without year), name, address, sex, and age. Membership numbers are sequential until 1,000, then begin again with number 1. When a person wishes to renew his or her membership, a new card is issued (with a new membership number) and the old card is destroyed. Therefore it is difficult to analyze renewal rates. There are few recurrent costs associated with administration of the insurance plan. Since the plan began, no new registers or membership cards have been purchased. The membership verification process is very simple (the receptionist compares the membership card to the person's national ID card), and accounting is combined with that of the health center, so personnel expense for record-keeping is negligible. The current cost of printing a membership cards is about 20 Z ($0.06), so the card expense for the 620 current members is approximately 12,400 Z ($35). To identify plan members, as mentioned above, the membership card is compared to national ID card. Cards are not checked against the membership register. Premiums are deposited in an account at the parish, as are all receipts of the health center. A member of the Development Commission works at the health center as an administrative assistant, and prepares a monthly financial report according to the SPTK model. The report shows cash flows as well as an income statement. Premiums are recorded as a cash receipt, but not as income. No interest is earned on premiums. 3. Resource Mobilization: Financial Situation of Plan and Center Table C.3 presents the combined financial situation of the insurance plan and the health center for 1988 and 1989. The data show that the health center is extremely profitable, with a margin of almost 65% in 1988, and 52% in 1989. Insurance premiums and member co-payments do not contribute a 38 Table C.3 Finmncial Situation, St. Alphonse 1988-1989 Nominal Zaires 1988 1989 l) ......... .............................. I--------............... X of Total Exp.1 X of Total Exp. OPERATING REVENUE ...................... I---------------------- Insurance premium 88,090 4.2K1 77,625 2.2X Member episodes 279,300 13.3X1 303,225 8.7X Non-mesbers firat vfait 1,158,950 55.1X12,017,080 57.6X Non-m mbers other visits 823,860 39.2X11,470,525 42.0% CPN & CPS 110,600 5.3X1 469,350 13.4X Sale of drugs C*) 544.080 25.9K1 171,675 4.9% Laboratory (+) 265,960 12.6X1 579.150 16.5X Sale of foodstuffs 163,580 7.8X1 195,150 5.6X Other 33,710 1.6K1 33,000 0.9X TOTAL: 3,468,130 164.9%15,316,780 151.7X OPERATING EXPENSES | Personnel 832,426 39.6X 11,962,990 56.0X Drugs and med. supplies 977,856 46.5X 11,215,200 34.7% Supplies, util., mint. 177,121 8.4X 322,043 9.2X Purchase foodstuffs 34,475 1 6K 4 500 0.1X Other 81,785 3.9X I 0 0.0C ---------....---1------------- TOTAL: 2,103,663 100.0% 13,504.732 100.0X BALANCE: 1,364,467 64.9K11,812,048 51.7X * 1989 fIgures extrapolated based on 8 months of actual data A* fter Nov. 1988 reverse from sales of drugs drops sharply. This my Indicate a chnge in pa wAnt system (more drugs included per episode) Laboratory receIpts recorded only for May through Dec. in 1988 Exchange rates whd Inflation rates for each year are found in Amex III large amount to the total revenue of the health center in either year Examining revenue as a percentage of total expenses, premiums covered 4.2% of expenses in 1988, and only 2.2% in 1989. Member co-payments covered another 13.3% of expenses in 1988 (8.7% in 1989). In both years, nearly all of health center expenses were covered by consultation fees paid by non- members. Other services (sale of drugs, laboratory, preventive care, etc.) contributed to the positive margin. 4. Udlization Table C.2 showed member and non-member utilization for curative care cases, and combined utilization for preventive care. Member episodes accounted for 13.7% of all new cases of illness in 1988. This share dropped to 10.3% in 1989. Unfortunately, follow-up visits for members are not recorded by the health center, so it is not possible to evaluate from its utilization data whether payment by episode encourages members to come back to the health center more frequently than non-members. For non- members, from 1988 to 1989 the number of visits per episode of illness increased dramatically from 2.9 visits per episode to 3.6. Changes in the relative price of follow-up visits compared to the initial visit may explain some of this difference (the relative price of follow-up visits 39 dropped in the first two months of 1989, then increased again in March). It is also possible that the diligence with which records are kept at the health center improved somewhat in 1989. To better understand the characteristics of insured and uninsured patients, a random sample of consecutive ambulatory patients was surveyed in October 1989. The questionnaire was written in French and posed in Lingala by bilingual Zairois interviewers (see Annex V). Table C.4 presents the characteristics of respondents by insurance status for this plan and the CASOP, the other Kinshasa case study, described below. Table V.2 in Annex V documents the decision rules for resolving missing and ambiguous data on membership status, which arose in 9% of responses.At the St. Alphonse center, 79 patients responded of whom 13% were insured. At the CASOP, 126 patients responded of whom 51% were insured. Table CA4 Kinshass Survey: Population Characteristics Insured Uninsured Valid Characteristic (HW74) (Hu131) Responses .. ................. ................................................... Center: St. Alphonse 14X 53X 205 CASOP 86X 47X Gerder: Female 44X 63X 205 Male 55X 34X Age group: 0-14 10X 11X 205 15-44 79X 76X 45 and above 11 13X Average + S.D. 29 *14 27 +13 Receives a salary each month 42K 33X Occupation: Professional, "cadre" 7X 10X 205 Skfiled worker 13X 8X student 24X 16X Unskilled worker 24X 16X Former 1i 2X Other 11X 13K None 20K 35K Eqployer: State 21K 6X 205 Pare-statal enterprise 3X 2X Private enterprise, for profit 11K 14X Private enterprise, not for profit 6K 3X Independ"nt 1K 7X Household 1X 2Z Other Os 1X Hone or no response 56X 66X Coqen poys for mdical care.: In full 35X 19X 205 Some 6X 3X Hon 3K 13X Hot eployed 56X 66X Is nother ftily meber _ployed nd covered for medical expenses? 44X 27X 202 ..................... ........................................... 40 As time for pretesting the survey and training the interviewers was limited to a few hours, the survey should be viewed as an indication of characteristics rather than a prec,se scientific inquiry. The resu!ts show that both insured and uninsured patients are young adults, of whom about a third are emiployed. Insured patients tend to be slightly more likely to be employed ^nd have better jobs than uninsured, but differences are small. Table C.5, based on this survey, shows actual paymeLl's reported by insured and uninsured patients for their current episode. The results show confirm that uninsured patients do pay more than insured patients, but both groups do pay something. These data from an independent source (the patients) confirm that actual charges are consistent with the official price list. Table C.5 Kinshasa Survey: Iltness and Expenditures. ................................. ........................................................ ..................... ...... Insured Uninsured (074) WMzl3l) Characteristic Mean SO Mean SD ....... ............ ............ ......................... .. .. ............. Duration of present tltness episode in days 53 225 27 109 First visit for this episode. 35X 39X Number of previous visits for current episode 2.0 2.6 1.6 4.2 Payment for current visit In Zaires 222 521 511 856 Total payment for current visit incLuding: Lab., x-ray end consultation SO.00 - t0.99 (O - 430 Zafres). 90° 76 *1.00 - #2.00 (430 - 860 Zaires). 4X 7X 52.01 - S5.00 (861 - 2150 Zaires). 4X 10X More than S S (More than 2150 Zaires) 1X 7r MAN 0.5 1.2 Nedicine included in total payment: Altl IncLuded 57X 56X Some inctuded 42X 43X None included 1X 1X Total payment for sit previous visits for current episode in Zefresmeen SD) 115 309 308 1,106 Expect wny follow up for this episode 85 85X Table C.5 also compares utilization data of insured and non-insured respondents. The results demonstrate some moral hazard or adverse selection, in that insured respondents had more previous visits. Table C.6 further describes the attitudes of the two groups. Insured persons tend to be slightly better off than uninsured; for example, the time they would require to mobilize 50,000 Z (S 125) was less than for uninsured respondents. Table C.7 presents questions asked separately of members and non-members. It is striking that 43% of non- 41 members had not heard about the plans before. Thus, posters and displays at the plans' clinics about the insurance system might be an effective and inexpensive way of increasing enrollment. Table C.6 Kinshasa Survey: Population, Attitudes and Opinion ..... . . . . . . .. . . . . . . . . . . . . . . . . . . . . . Insured Uninsured Valid Characteristic (1174) WMUI3I) Responses ....... ..................................................... Wiould you be able to pay 10,000 Zaires 205 for an illness requiring minor surgery in a hospical? Could pay today 35X 34X Could pay some other day' 58X 552 Could never pay or no response 72 112 * After how many days? (Average) 11 12 Would you be able to pay 50,000 Zaires 205 for an Illness requiring minor surgery in a hospital? Could pay today 132 112 Could pay some other day' 752 70X Couldc never pay or no response 132 20X * After how many days? (Average) 30 40 Where would you get the 50,000 Zaires (see question above)? 205 Cash, from household 38X 222 Saving clubl or association 11X 6X By selling household items or Livestock 52 102 Taking a loan from somebody outside the household. 232 232 Donation from somebody outside the household 02 1X Contribution of famiLy mrbers 92 192 Other 3X 42 No response 112 152 Would you suggest this insurance plan to other family mnbers? 852 85X 135* What do you think of the organization 205 of health insurance schemes? Favourabte 962 922 Not favourable 1X 3X Do not know or no response 3X 5X .. ................. ...................................... ... * Applicable only to St. Alphonse. In CASOP, filies had to join. Table C.7 Kirahass Survey: Questions Asked Separately of Insured and Uninsured Respondents ..................................................... QUESTIONS 2 What are the inconweniences or problem of your bership? Too expensive 6.92 Benefits not worth the fees I pay 1.42 It is necessary to cow for follow kV visits. 26.4X Other 15.32 lNothing 47.2X 42 LWy are you not meaber of the insurance plan? Too expensive 15.9X I have no money 7.9X Why should I pay before I m sick? 4.0X Never heard about this before 42.9X I * not often sick 0.8X I did not know at the time of enrollment 10 .3 I do not trust this insurance 5.6X I can pay for each consultation 9.5X Other 3.2X ...... .......... _.................................... As in Bwamanda, it was difficult to characterize the insurance status of about 18 respondents (approximately 9% of the respondents). As shown in Appendix Table IV.2, however, it was possible to impute the membership status based on responses to other variables. 43 D. CASE STUDY OF CASOP The Caisse de Solidarite Ouvriere et Paysanne (CASOP) is sponsored by the Zairian National Workers Union (UNTZA). The health insurance plan is only one of the many social services provided by the CASOP, which operates nationwide. The research team studied how the insurance plan works by looking at the CASOP's only polyclinic in Kinshasa, which serves all CASOP members in the city. 1. Terms of the Insurance Plan The CASOP plan covers ambulatory curative cases of illness treated at the CASOP polyclinic in Kinshasa. Plan members are entitled to pay a lower fee than non-members for each day of care, which includes a nurse consultation and some basic drugs. Families of members are entitled to the same benefits as members, for no additional premiums. Table D.1 contains a list of prices according to payor category. Theoretically, there are four categories: individual member, individual non-member, company member, company non- member; but there are currently no companies which are affiliated with CASOP's clinic that are not members, so in effect there are three active payor categories. Individual members are insured and pay least. Individual non-members are uninsured individuals. Company members are insured and benefit from having their companies billed the fees for their services. For all payor categories, laboratory exams and x-rays are charged separately. Drugs which are not usually kept in stock at the health center level are charged separately as well. TabLe 0.1 Price Lfst CASOP PoLyctinic, 1989 l ~ ~ ~ ~ ~~I i I COMPANY ISERVICE I MEMBER IMON-MEMBERI MEMBER I I------ ------------------- ------------------------------- fConsuLtation with: I I I IMedicat Assistant 2 250 1 350 1400 iGenerhl Physician I 350 1 500 600 Ispeciitized Physicien* 450 | 700 j 800 |IV with drug 1300 | 1550 1600 0 ILaboratory: BLood | 100 1 200 | 200 I ILaboratory: Stools I 100 I 200 1 150 I I I I I I INorml delivery 7 7000 I 10000 | 12000 jXray (chest, adult) | 1400 1500 I 1700 | .......................................................... * This Is the type of coanultctlon chosen by out petients according to the cifnic adeinistration. The clinic also provides prenatal care, vaccinations, nutrition demonstrations, and minor surgery, all of which are not covered under the plan. Nationally, the CASOP has more than 42,000 contributing members. When family members are included, the total reaches one quarter million. In Kinshasa, the total number of members (including families) was 6,691 in September ;989. Since membership is open to the entire population, this represents a tiny fraction (0.2%) of Kinshasa's total population of 3 million. 44 While all CASOP members and their families may use the polyclinic, Table D.2 shows that UNTZA staff and families account for a large fraction of utilization (34 to 47% of new cases in 1988 to 89). UNTZA is a company member', and is billed for the wco-payments' of employees treated. Table 0.2 UtIlization, CASOP Polyclinic, Kirnshasa, 1988-1989 ................................... .......................................................... 198 189 2 aIL 2l OtL 2l tlt IVisitinruber 1I 1 1% IVisitl PATOR VPE OF Inumber Inew ifolLowitotal lper 1(9 mo.)ltotal Inww Ifollowiper I CATEGORY VISIT I () Ic ese, icaes lass$ Ispia. (C) |util cases Icases Iepia.1 . .--..I.I….I.I.I.I. .II-------.I------ I------1------1----1----- I----1-- I--- ----- I--I--1 ILUITZA INew 110,548 | 47.5X1 --- I -- I | 3,628 1 33.7X1 --- I --- I I |staff IFoltow-upl16,269 I --- I 55.8X1 ---I | 8,987 1 --- I 48.821 --- I I .......... ITotal 126,8171 I --- 1 52.2X1 2.5 112,615 1 -- I -- 1 43.2X1 3.5 1 . ...... I---- --- - ------I- ----1-- ----- --1-- ---------1------1-----I IIndiv. INew 1 5,325 1 24.021 --- I -- I 1 2,456 1 22.821 --- I --- I I Ins'bers IFoltow-upi 6,793 1 -. 1 23.321 --- 1 3,591 1 -- 1 19.521 --- I I | iTotal 112,118 1 --- I --- 1 23.6X1 2.3 1 6,047 | --- I -- 1 20.7X1 2.5 i 1-- -------- I--------1-I------1-I-----1-I-----1-I-----1-----------1I------ 1I------ I----1- I... IColany INsW 1 4,079 1 18.421 --- I ---I 1 2,988 1 27.721 --- I --- I I lbilted IFollow-upI 4,434 1 -- 1 15.221 --- I 1 4,102 1 --- 1 22.3XI --- I I lm.& non iTotuL | 8,513 | --- I --- 1 16.6X| 2.1 1 7,090 1 --- I --- 1 24.3X| 2.4 1 1----------1 I--------1I-------1 ----- 1------1- I------ I ------- I-1-----1 I-----1I------1I-----I Nmon- INew 1 2,264 1 10.221 --- I ---I 1 1,707 1 15.821 --- I --- I I Ibers IFotlow-upl 1,648 1 --- 1 5.7X1 ---I 1 1,751 1 --- I 9.521 --- I I .Total | 3,912 | --- I --- 7.6X| 1.7 | 3,458 | --- I --- I 11.8X1 2.0 1 ........ I-----------1I-------1------ I----- -1-----1-----1---- ---1------1 I-----1-I-----1-I-----1 ITOTAL INew 122,216 1100.021 --- I --- I 110,779 1100.021 --- I --- I I IALL PAYORSIFollow-UP129,1" I --- 1100.0X1 --- I 118.431 1 *-- 1100.021 --- I I I ITOTAL 151,360 1 --- I --- 1100.021 2.3 129,210 1 --- I --- 1100.021 2.7 1 . ......... ......... ................ .... ...... .. ...... ......... ....... ............. ............. Jan. to Sept., *xcluding April (no data avail. for April) Foatlow-p visits are calculated by dividing totaL receipts by price per follow-up visit. The monthly contribution to CASOP is 100 Z ($0.28) for the average worker. Honorary members (people with large incomes--self-identified) pay 200 Z ($0.56) per month, while farmers ('paysans') are charged 50 Z ($0.!4). In fact, the latter tariff is not used, since most people are able to afford 100 Z in the urban area of Kinshasa. Upon joining CASOP, members must pay a one-time fee for the membership booklet (100 Z), and six months of contributions in advance, or a total of 700 Z ($1.98). People who fall in arrears of their monthly dues are given three months to pay up the full amount. If they cannot pay back dues by the end of three months, their membership is suspended. Companies (e.g. UNTZA) which join the plan for their employees pay for the membership booklets, ard use payroll deduction to collect the monthly contribution from the employees. Individual members are subject to a co-payment. Since the end of 1987, their co-payment has been 450 Z ($1.27) for one day of care. (See Table D.l) A price change is planned very soon. Companies are billed at the individual member's 'co-payment' price for the services provided to their employees. Laboratory, x-ray, minor surgery and some drugs are charged separately. There are no caps on spending. 45 The insurance plan is voluntary for individual members. Companies may join voluntarl,, but once they have joined they must enroll all their employees. The employees are then required to make the monthly contributions. The health center treats patients who are not members of the insurance plan. Table D.2 showed that non-members accounted for between 9 to 10% of new cases in 1988 and 1989. A similar payment system applies, only non-members are charged higher prices. The average number of visits per episode of illness for non-members is lower than the overall average (1.7 compared to 2.3 in 1988), possibly showing that higher prices discourage people from secking follow-up treatment. 2. Organization and Management CASOP began in 1968, as a Christian mutual. When management changed into the hands of the Zairian Workers' Union, the name of the association changed. CASOP existed a long time before the polyclinic was added. By making a monthly contribution to CASOP, members receive benefits in the case of marriage, birth, hospitalization, need for social assistance, unemployment or a death in the family. The level of benefits is set in advance, usually on an annual basis. For example, a member who contributes 200 Z ($0.56) per month will receive a hospitalization benefit of 50 Z ($0.14) per hospital day. Family members are entitled to 25 Z ($0.07) per day. The member contributions are collected and managed by committees at the local level ("comite primaire"). These local funds are divided into differeLt pools, according to standard formula. For example, 10% of funds are reserved for hospitalization benefits, 35% for death benefits, 3% for marriages. The local committees must contribute 17% of the funds to the polyclinic, and 15% to administration at the regional and national levels. When the polyclinic first opened, CASOP's idea was that membership contributions would enable the clinic to provide care at no price to members. This soon proved impossible, because utilization was high aind the services were too expensive. Health services received only a small portion of the premium. As CASOP officials felt that a higher premium would not be affordable, they introduced co-payments instead. Polyclinic staff are all UNTZA personnel, and are paid through the UNTZA personnel office and not through the polyclinic. This situation is changing, however; a decision was made in May 1989 to make the polyclinic more independent from UNTZA. CASOP is a direct insurance plan, offered by the provider. This status may change, howevcr, as the policy of making the polyclinic 'more independent" evolves. Accounting for the insurance plan is mingled with that of the clinic. The monthly contribution amount is set to take into account the costs of the benefits covered (hospitalizations, deaths) based on benefits paid out in the past and the cost of living in Kinshasa. It isn't clear how the percentage of the total fund allocated to the polyclinic (30% in 1988, 17% in 1989) is set. Individuals may join the plan at any time during the year (even when they are sick), with coverage starting immediately and lasting until the member stops paying dues. Enrollees receive a membership booklet which specifies name, age, membership number, date joined, profession and marital status. A photo of the member is included as well. Similar information is filled in for the spouse; for children, name and age arc recorded. There are many pages in the booklet, where stamps are affixed to record payment of monthly contributions. It is difficult to estimate the recurrent cost of administering the insurance plan, since it is part of a larger social insurance program with many administrative levels. The membership 46 verification process is not time-consuming (the receptionist checks the membership card to be sure it is us? to date, or notes the employee ID number in the case of company memberships). It was difficult to assess the accounting procedures followed for billing company members or monitoring the insurance plan. Premiums are paid to local committees, who forward a percentage of the premium payments to the polyclinic. The amount received by the polyclinic in 1988 (fiscal year ending October 1989) was approximately 403,980 Z ($1,140). 3. Resource Mobilization: Financial Situation of Plan and Clinic Despite repeated attempts to obtain financial data about the receipts and expenses of the polyclinic, the team failed to obtain any financial reports or summaries. The accounting systems of CASOP and the polyclinic are in extreme disorder. 4. Utilization Table D.2 shows member and non-member utilization for curative care cases. Individual members accounted for 23 to 24% of all new cases of illness in 1988 and 1989. UNTZA staff, who benefit from company membership', accounted for 48% of new cases in 1988, but only 34% thus far in 1989. Non-members accounted for only 10% of all new cases treated in 1988, however the percentage of non-members seen has increased to 16% in 1989. The number of visits per case for non-members is lower than the average (2.0 compared to 2.7 in 1989). The highest number of visits per episode is found in the UNTZA staff group, with 3.5 visits per episode. The greater number of visits among insured persons suggests that moral hazard or adverse selection operates to some degree. 47 E OTHER INSURANCE PLANS Some descriptive information was obtained on four other insurance plans. The findings are summarized in Table E.1 and described below. Table E.1 Characteristics of Other insureace Plns ,.......................................................................... REIEF NASISI UPW SNHR .......................................................................... Region Kinfhasb Kivu Notional Rutshuru Hz (Shlaba?) Ruralt/Urban Urban Rural Painly Urban Rural Mnagement Zairian PVO Health Zone Zafrian PVO SNHR Year Started 19b6 1988 1966 ? Eligible MM00 214,240 8 sillion SNHR .mbers Population & fmilies Nuwber of roo to 1000 7 few 20 fmilies Nf"rs Services All hosp. & ob. Hospital Hospital Hospital Covered incL. referrels services & ambulatory services Premiu 500/mo. sdult 150 Z/ year ? SDOZ/o. 250/mo. child Discounted rates for poor L farmers , .. . ........ ........................ .................................................. 1. Reseau Medecins de Familles (REMEF) REMEF is a direct insurance plan which functions like a ataff health maintenance otganization (HMO). Started in February 1986 by a Zairian doctor who had studied family medicine in the United States, the REMEF clinic is the base for medical staff who provide comprehensive health services and outreach activities to the families in the nearby communities. The REMEF has benefitted from some Canadian assistance and sponsors a private nursing school in addition to the polyclinic. The focus of the REMEF is maternal and child health services. Li. Terms of the Insurance Plan The REMEF insurance plan covers all ambulatory and inpatient services, including drugs and laboratory, surgical interventions, and preventive care services. In May 1989 the polyclinic moved to its current location, where yive beds are available for hospitalizations. There is an additional maternity bed as well. If a patient requires referral to a secondary hospital or medical specialist, the cost of the referral and all subsequent services is assumed by the plan. While no census exists, the size of the community served is assumed to be about 7,000, of whom 48 between 700 to 1,000 (10 to 14%) are members who pay their monthly premiums regularly. Since 1986, the REMEF has had a total of about 2,000 members. Currently small local businesses who enroll employecv and their dependents account for 557 members, or between 55 to 80% of total membership. In 1989, the adult monthly membership premium was set at 5;80 Z ($1.41), or 6,000 Z ($16.92) per person per year. Students and children are charged a lower rate of 250 Z ($0.70) per month, or 3,000 Z ($8.47) per peCson per year. Farmers ('paysan") are also charged the lower rate of 250 Z. A full-time public relations worker assumes the task of verifying membership category, either by calling schools or making home visits. Lower income families may be charged different rates, depending on the decision of the REMEF administrator, again pending investigation by the public relations worker. Company membership rates are the same as individual rates. The plan has no limits on spending or duration of episodes of illness. There are no deductibles or co-payments. Membership is voluntary (except in the case of company employees) and whole families are not required to join if one member joins. The plan covers both treatment at the facility as well as the cost of referrals elsewhere. Non-insured residcn:s may be treated at the faci'ity. They are charged 500 Z ($1.41) for each consultation, with drugs and laboratory payable separately. It is rare that non-members come to the facility to be treated, however. L Resourc Mobilization - Record-keeping is not well-developed at the REMEF polyclinic, so it is difficult to analyze the financial situation of the plan. No utilization registers or financial account books were available for review, and procedures for recording and verifying membership seem lax. To gain some estimate of the size of operations, salary information was obtained for polyclinic employees other than doctors. Monthly salary expense excluding REMNEF's two doctors (one of whom is the Director) is approximately 95,000 Z ($268). Assuming a salary of 150,000 Z per month for each doctor (the high-end of the Bwamanda pay range), total personnel expense is about 395,000 Z ($1,115) per month, or 4.7 million Z ($13,380) per year. Since personnel expense probably accounts for 60% of total expenses (it was 56% at St. Alphonse), REMEF's total annual expenses for polyclinic operations may be 8 million Z or more ($22,590). Revenue from premiums cannot be estimated accurately, since the number of individuals falling into each membership category is unknown. But even if all members were adult and the maximum membership figure is assumed (1,000), revenue only comes to 6 million Z per year. This indicates that REMEF may be receiving external operating subsidies from some source, or that the estimates of doctors' salaries and/or total membership are wrong. 1,1 Utilization 'Ttilization figures were available for two months, August and September 1989. These figures sn,o)w that utilization is much lower than either CASOP or St. Alphonse. REMIEF treated an average of 152 new cases per month in Aug. to Sept. 1989, whereas the average number of new cases treated each month at St. Alphonse is about 528, and at CASOP the number is close to 1,200. REMIEF't utilization data are shown in Table E.2. 9 The average family size of these members is small (3.2) which may be due to the large number of single persons employed in the hotel industry. Two small hotels are among the businesses which have contracted with REMEF to provide health care to employees. 49 Table E.2 Utilization Data (Cll patients) at REMEF Aug. 89 Sapt. 89 New Cases 138 16S Follow-up Visits 147 162 Hospitalizations 19 3 Deliveries 3 4 Transfers 0 1 Growth Monitoring Visits 35 26 Dwes of Vaccines Administered 128 141 REMEF's staff is dedicated and quality of care seems very high. The facility was extremely clean, bright, well-supplied and well-equipped. Technical assistance in organization of management systems and in management training would be well-placed, to assure continued evaluation and success of this health insurance experiment. The PASS may also wish to conduct a more detailed analysis of the costs associated with the plan, especially the plan's policy of paying for the treatment costs of all cases referred to other providers. 2. Masisi Health Zone Insurance Plan The rural h, alth zone of Masisi is located in the Kivu Region, covering a population of approximate.y 214,240. Only recently started, the health zone benefits from the assistance of a Belgian Cooperation Zonal Chief Medical Officer who has had previous experience starting-up the zone of Kirotche, in the same region. Masisi has a 142-bed reference hospital and 19 health centers or health posts. To increase econcmic access to health services the zone began offering a health insurance plan in 1988. The Medicin Chef de Zone (MCZ) delivered a presentation about the insurance plan at the SANRU national conference in 1989. Since the research team for this study did not have time to visit Masisi, this section is based on the MCZ's presentation at the SANRU conference, as well as conversations with staff from the Belgian Cooperation and SANRU. 24. Terms of the Insurance Plan The plan covers all hospital services including deliveries and chronic care. The premium charged in 1989 was 150 Z (S0.42) per person per year, calculated on an actuarial basis assuming a hospitalization rate of 4.9%, an average cost per hospitalization of 2,000 Z (about SI I in 1988), and a 5G% margia for inflation. Premiums are invested in the purchase of drugs for the central pharmacy. The hospital bills the plan for services rendered to members. Members are identified by a membership card which is compared to a membership register kept at the hospital. Enrollment of members takes place at the health center and community level, with the assistance of village health workers and health center nurses. Family enrollment was not required in the past, but is now seen as an important ingredient to financial sustainability, as discussed below. 2, SUtilization and Success of the Plan Enrollment figures are unknown, but the experience of the first year showed that enrollment was low and the plan was in deficit after only six months of operation. The MCZ attributes SO the early failure of the plan to the problem of adverse selection. His solution was to try to enroll greater numbers of the population, and to require that whole families join if one member within one family joins. The MCZ also observed that it was very difficult to enroll residents who lived far away from the hospital. More than price, distance seemed to have a much greater effect on access to hospital care. According to the manager of the SANRU project (which provides assistance to Masisi), an additional constraint may be the lack of village structure in the area, which makes community organizing and the conduct of awareness campaigns difficult. The Masisi experiment is ongoing. The study team encourages the Government of Zaire to monitor tnis experiment and conduct an evaluation of its success after two full years of operation. 3. Mutuelle 'Union et Prevoyance (UPM) Created in 1986, the UPM is a non-profit association sponsored by several workers unions and medical providers, including UNTZA, the Confederation Internationale des Syndicats Libres (CISL), the Confederation Mondiale du Travail (CMT), the Clinique Internationale de Kinshasa, Mecial Service International, and the Institut National de Securite Sociale (in 1988). The UPM is currently operational, but on a very limited basis. The plan is proposed to be extended nationally, and is indirect (i.e. the UPM is not the health care provider). It's objective is to offer both ambulatory and hospitalization insurance to the employed population through contracts with health centers and hospitals. 4. SNHR Employees in Rutshuru According to a USAID official, 20 employees of Service National d'Hydrolique Rural (SNHR) in the rural station of Rutshuru (south-eastern Zaire) started a small cooperative, to assure financing for health care needs of the group and family members. In principle, the SNHR pays for health care services for the employees and their dependents; however, in practice hospital bills were left unpaid. Finally, the hospital began refusing to treat the SNHR employees unless they paid cash in advance. The employees decided to organize themselves and create an insurance fund; they began by contributing 500 Z ($1.41) per employee per month to the fund. Decisions to spend the insurance money are made by the whole group, on a case-by-case basis. According to the USAID official, the experiment seems to be working well. The team suggests that future research regarding insurance should try to obtain more information about the success of this experiment. 51 F. INFORMAL ASSOCIATIONS To explore a possible base for insurance systems in existing informal savings associations, a Zairian sociologist conducted interviews with 50 members from 17 associations. Fourteen of the associatioas were located in Kinshasa, while three were in Bwamanda. The sociologist also drew on her previous research and publications on "likelemba" and "moziki" associations, conducted for the Department of Women's Condition (21). Likelemba associations are strictly rotating savings clubs, where members contribute a set amount at a set time interval, with one member receiving the pool at each collection interval. For example, in a likelemba with ten members, each contributing 1,000 Zaires per month, the "savings pool" is 10,000 Zaires, which will go to a different member each month. The members of a likelemba association do not need to meet each time the collection takes place; usually one person is assigned the task of collecting the members' contributions and distributing the pool to the recipient. There are no provisions for paying interest or 'bidding" to obtain a more favorable (earlier) place in the cycle as occurs with Wang shares in Thailand; however, people who received the savings pool early during the first cycle move to the end for the second cycle. Moziki associations have the same structure of a rotating savings club and add two additional featurcs. First, moziki members get together for a social gathering at the time the collection is made. Members make regular contributions toward the refreshments for this gathering. Second, the moziki associations often include an emergency loan fund ("caisse de secours"). Members contribute a fixed amount to this emergency fund each time they get together. If a member is in difficulty and needs to raise a large sum of cash quickly, he or she can request a loan from the emergency fund, repayable usually within I to 2 months, without interest. At the end of the moziki cycle (i.e. when each member has had a turn to receive the money from the savings pool), the emergency loan fund is divided up and redistributed evenly to all members. As an indication of the frequency of such associations, an administrative census in Bokoro town identified 12 likelemba or moziki which have over 1,000 registered members. Another association in Kempa (12 km from Bokoro) counts 100 members. Of these 13 associations, 8 made payments for hospitalization. Eleven likelemba associations and six moziki associations were surveyed. The general characteristics of the associations are discussed below. 1. Size and Membership The associations ranged in size from 4 to 20 members, with an average size of 10 members. The likelemba were slightly smaller than the moziki associations. In about half of the associations all members were of the same sex. In both types of associations, 65-68% of members were female. Members represented a range of occupations: ;nerchants and traders, food sellers, salaried workers, teachers, government employees, housewives, and some "family' associations (including members of the same family). Six of the associations regrouped people with the same occupation or employer. More than occupation, trust and rapport among members, as well as a similar ability and willingness to save, seemed most important to the success of an association. 2. Contributions Frequency of contributions and meetings ranged from every two days to once a month, with members contributing from 1,000 Z ($2.33) to 100,000 Zaires ($232.50). Comparing equivalent monthly contributions, the average contribution for the 17 associations studied was 20,600 Z 52 ($47.91). Excluding three associations with contributions of 50,000 Z or higher, the average drops to 13,353 Z ($31.05). 3. Reasons for Saving Fifty members were asked what they would do with the savings pool when it was their turn to receive it. The most frequently cited responses were business investment (44%) and purchase of a household durable good (34%). About 8% said they would use the money to pay for education, while 14% cited other uses, including purchase of clothing or jewelry, financing for a trip, and security deposit for housing. Since school fees are usually paid in August and September, most members had probably already found the funds to pay for education by the time of the survey in October, thus education did not rate high among reasons for saving. Surprisingly, no members cited purchase of health care services as a reason for saving. The emergency loan funds organized through moziki associations were used to purchase health care, however, as described below. 4. Emergency Loan Funds Four of the six moziki associations studied had emergency loan funds to which members contributed regularly. Equivalent monthly contributions to the loan fund ranged from 900 Z ($2.09) to 2,000 Z ($4.65) per member, creating a monthly pool of 9,000 to 40,000 Z ($21 to $93). Since the loan pool is additive, the total pool can grow to 81,000 to 800,000 Z ($188 to $1,860) by the end of the cycle. In the four associations with loan funds, 10 of 54 members (18%) had received loans in the past 12 months. Loans ranged from 10,000 to 50,000 Z ($23 to $166), with an average loan size of 27,500 ($64). Four loans were made for health-related reasons; three helped finance birth, and one was for a non-maternity hospitalization. Other reasons for loans were deaths or marriages. Loans were repaid in I to 2 months, without interest. An additional function of the loan fund is to assure that the association does not falter because one member fail make his or her contribution during a particular interval. The loan fund is used to complete the member's contribution, and the member repays the fund before the next meeting. In the two moziki associations without loan funds (both of which were located in the rural area of Bwamanda), members stated that collections were sometimes taken up for members facing extreme difficulties. This money was given, not loaned, to the member in need. In a recent case, 500 Z ($1.16) was collected from each member for a total of 3,000 Z ($7) to give to another member who had been hospitalized. This amount represents about two-thirds of the standard price of a hospitalization in the internal medicine ward. 5S Use of Money Lenders for Medical Emergencies A recent World Bank study of savings and credit cooperatives in Zaire documents the use of money lenders as a source of informal credit (22). In the associations surveyed, members were asked if they had ever borrowed money from a money lender to pay for extraordinary health expenses. Of the 50 members surveyed, one admitted she had borrowed 20,000 Z ($46) to pay for her sister's operation. She repaid the loan in one month, with 50% interest. The sociologist conducting the interviews noted that the practice of using money lenders is considered embarrassing, however, so people may have been reluctant to admit that they used money lenders. 53 6. Rolea of Informal Associations In conclusion, informal savings associations are used by many people in both rural and urban areas as a way to put aside a block of money for large consumer purchases, predictable education expenses or business investment. The rotating savings funds are not used currently to provide a cushion of security in case of medical emergency or other unexpected needs. A subset of informal savings associations--the moziki associations--does provide a mechanism for financing catastrophic hcalth care by granting short-term loans to members. Because mcmbership in informal associations is very small (4 to 20 members), insurance schemes would not be feasible. The emergency loan funds are a good alternative, however, and associations should be encouraged to provide this service to members. Operations research might also explore the possibility of lengthening the repayment period for loans, and charging interest. These options may not be feasible, however, due to the short life of most of these informal associations. Most informal associations lasted less than a year, in the sense that membership generally turned over after one or two cycles when the savings objective had been obtained. Some of the same members may form a subsequent informal association, but it is considered a different association. The savings and credit study proposed many ways in which donors can help strengthen COOPECs (Savings and Credit Cooperatives), another more formal but still grass-roots type of savings association. The study team recommends that the PASS implement that study's recommendations, especially to provide training in financial management to COOPEC managers and administrative staff. As COOPEC organizations begin to function more effectively, the possibility of providing health insurance through COOPECs directly (or using COOPECs to help administer insurance plans) can be explored. 54 III. CONCLUSIONS AND RECOMMENDATIONS The case studies in this report have described 3 varied group of insurance schemes for rural and urban populations in Zaire. Several factors can be identified which favor or hinder the replicability and the development of health insurance plans. These conclusions summarize the 13 lessons learned from the case studies, and offer recommendations for next steps. Thc recommendations seek to strengthen existing systems, to learn from Zaire's rich experiencc in health insurance, to extend the existing systems, and to encourage appropriate initiatives. Our findings do not support the rapid implementation of a nation wide conventional health insurance system as a feasible solution. Instead, decentralized, locally managcd plaais seems to be a key success factor. A. TERMS OF THE INSURANCE PLAN l. The Insurance Schemes Cover Selective Types of Services Theories of risk pooling suggest that insurance is most appropriate for events which are infrequent but would cause severe financial hardship. Inpatient care and treatment of certain chronic illnesses in rural Zaire meet this criterion. A typical rural hospital admission costing $ 15, for example, would consume one month's income for a Zairois earning the per capita GDP. Several of the systems did, indeed, insure inpatient care: Bwamanda, REMEF, Masisi, and UPM. It was striking, however, that the systems in the other case studies (CASOP, St. Alphonse, and Bokoro) insured only outpatient care. The framers of the Bokoro plan had wanted insure both inpatient and outpatient care but found that the resources were sufficient only for outpatient care. Whereas the schemes in Bwamanda and Masisi explicitly covered care of chronic illnesses, the systems in Bokoro, St. Alphonse, and CASOP excluded it. Insurance for ambulatory services, while theoretically less important than inpatient services, seems more attractive to many consumers. As ambulatory care is frequently consumed, consumers will immediately recognize the value of insurance coverage. Also, insurance may provide a way to pay for care at a time that cash is more readily available, such as at hai * cst time. The consumer surveys in this study indicated the attractiveness of covering ambulator y care. Among insured respondents in Bwamanda, 81% would like to increase their premiums sufficiently to cover ambulatory care. Among respondents in the Kinshasa survey, 85% would recommend their current largely ambulatory insurance plan to their family. The argument against such insurance is that moral hazard (excessive use of the insuied services) and added administrative costs make such coverage much more expensive than paying for the services directly. 2. The Most Successful Plans Have Modest Premiums The fuller the range and depth of insured services, the higher the required premium is. Among the plans studied here, Bwamanda and CASOP had the most members, with 134,680 and 42,000 (nationlly) respectively. The 1989 annual premiums per family member were 125 Z (US $0.29) in Bwamanda and 1,200 Z ($2.79, a modest amount for Kinshasa) plus an enrollment fee in CASOP (100 Z per worker per month for an assumed family of 6). These plans limited services to those affordable within these financial constraints. T'ie Bwamanda plan was essentially limited to inpatient care that met three conditions: the patient had been referred from a health center within the system, hospital staff confirmed the need fol admission, and the care was provided *n the hospital offering the insurance. In CASOP, individual membership provided only a modest reduction in fees. At their Kinshasa polyclinic, insurance lowered the price of the most frequently chosen consultation (consultation with a specialized physician) by only 36%, from 700 Z for a non-member to 450 Z for a member. By contrast, in rural Bokoro the annual premium per person (not per family) was 1200 Z 55 ($2.79). In the survey in Bokoro, respondents indicated that they could afford an annual premium of 100 to 200 Z. The only subscribers in Bokoro were employees whose premia were paid by their companies. The plan insured only 4.5% of the zone's population. The premium was beyond the financial means of potential individual members. B. ORGANIZATION AND MANAGEMENT 1. An Acceptablc Quality of Services Is a Precondition for Insurance It is very difficult to measure quality of care without first developing common standards, and secondly conducting utilization reviews to examine the appropriateness of diagnoses and treatments, evaluate patient outcomes, and investigate deviations from standard protocols. Lacking common standards and historical utilization reviews, it is impossible to detect a causal relationship between the organization of a health insurance plan, and changes in quality of patient care. It is possible to record observations about general quality measures, however, including availability of drugs, training and level of staffing, and condition of infrastructure. It is also possible to formulate hypotheses about the nature of the relationship between insurance systems and quality of care, even if such hypotheses cannot be tested without additional data collection. A likely hypothesis is that health providers which offer insurance programs have higher quality of care than health providers which do not have any form of community financing system (user fees, insurance, or other). This is because community financing systems, including health insurance plans, increase the financial resources available to health providers, thereby allowing the providers to spend more on quality improvements (assuring drug supply, hiring and training staff, etc.). There is no reason to believe, however, that insurance systems would be any better at improving quality than user fee systems, except that insurance systems may be able to mobilize greater financial resources, depending on how premiums are priced, levels of enrollment, and how premium revenues are invested. Bwainanda, Bokoro, St. Alphonse, and CASOP, all had high quality of care, in terms of general indicators such as drug supply, staffing and infrastructure (see Table 11.2 in Section II). All four providers had a steady supply of drugs with very infrequent stock-outs. Bwamanda, Bokoro and CASOP all have several doctors and well-trained (A-I level) nurses; St. Alphonse Health Center has several well-trained nursing staff. All four facilities have good to fair infrastructure, with well-maintained buildings and most essential equipment. The facilities were busy with patients, suggesting that patients had sufficient confidence to spend their time and money to seek treatment. Compared to other health zones receiving donor assistance (for example, from the SANRU project or Sante Pour Tous Kinshasa), the quality of care at the facilities studied was about equal. Compared to non-donor assisted zones, however, quality was much higher. Studies elsewhere in Africa, such as Rwanda, have demon3trated that the population is willing to pay substantially for the availability of drugs [24]. If drugs are absent, patients lack confidence in the facility and few will use it. Before trying to develop health insurance, it would be important to assure that patients have confidence in the provider(s) covered under the insurance. If a health facility had poor quality due to inadequate resources, it seems unlikely that creation of health insurance alone could break the cycle. However, if some external assistance (funding, qualified personnel, donated supplies, or technical assistance) could raise quality and confidence for a period of time, then insurance could help make those improvements sustainable. 56 2. Voluntary Schemes Have Found It Important to Sensitize the Population To obtain widespread enrollment, a voluntary insurance system needs to sensitize the population to its value. In systems organized through a health zone, the workers in that zone can organize this enrollment. In Bwamanda, this awareness campaign functioned well and over 60% of the zone's population was enrolled in both 1988 and 1989. As enrollment occurred at a specific time, village meetings were held at that time to promote the system. Health workers received a commission (3% of the premiums they collected) to reinLorce their enthusiasm. In Bokoro, on the other hand, workers in health centers received no incentive, did not appear interested in the subscription plan, and enrollment was low. In St. Alphonse, the parish development committee promoted enrollment and conducted a door-to-door campaign, though current enrollment is only about 6.2% of the population of the urban zone. (As this approach probably permitted only a single contact with each potential enrollee, it may not have been that effective.) Because village leaders often command the respect of the population, their endorsement of a new system can be a strong force in sensitizing the population to the value of a new system. There may be many more opportunities for well functioning voluntary associations to add health insurance to their activities. The Commission mentioned in the introduction to this report identified 562 currently operating associations of all types. A health provider could work in partnership with several mutual associations in its vicinity to offer health insurance. The health provider would offer preferred access to members of the affiliated voluntary associations. The associations would provide some oversight over the quality and charges for services and would market an insurance system to its members. In the United States, many professional associations offer life and health insurance to their members in this way. 3. Committed, Decentralized Management Provides Flexibility and Accountability All of the systems studied were under local control. The one national system, CASOP, delegated financial responsibility to local councils. Decentralization can be important even within an insurance system. In Bokoro, each health center exercised some control over its profits. As only a 25% share was allocated for its immediate use and deficits could be passed on to other health centers, there was little incentive for good financial performance. All of the systems visited in the course of this study were run by health providers. These so called direct insurance systems offer important advantages in efficiency and control over indirect insurance systems, in which the insurer pays some independent provider for care. The indirect systems raise many questions of financial control. The insurer must assure that the member needs the service being requested, that the chosen provider is competent to perform the service, that it actually was performed, that the insured is the actual recipient of the service, and that the fee was appropriate. In a provider based system, many of the inherent conflicts between the insurer and the provider are avoided. Committed administrators contributed to the success of the Bwamanda system. The director of the CDI Medical Service is a Belgian physician who has worked 14 years in Bwamanda. Other personnel, from the insurance plan administrator to the health center nurses, also believed in the system. While nurses welcomed the commission of 3% of the premium income they collected, they also seemed .o appreciate being part of a well functioning system that allowed them to use the locally available resources to provide health care to their population. 4. Simple Control Methods Can Rcduce Risks of Error or Fraud Widespread error or fraud would undermine the financial viability of a health insurance 57 system. Control is required for several steps. The case studies have identified useful approaches for many of them. (a) Assuring that premium income is received and accounted for for all gersons recorded asD2yin&. The system of printed stamps in Bwamanda provided a useful device. Each health center is issued a specific quantities of two-part enrollment stamps during the enrollment period. Upon payment, a member is given a stamp for each household member. At each supcr' isory visit during enrollment, the zone's financial officer withdraws the cash on hand and verifies that it matches the value of stamps distributed. (b) Assuring that persons claiming to be insured have paid the current premium. Again, in Bwamnanda one part of each of the above-mentioned stamps was affixed to the back of the family's health card kept at the center; the other to individual cards retained by each person. All stamps are signed to validate them. When a member seeks hospital care, he (or his guardian) must present his health record with the current signed stamp on the back. (c) Preventing a non-insured person from easily borrowinu the card of an insured individual. In CASOP, members had photo identification cards, a technology that is relatively expensive in Zaire. The cards were feasible for CASOP because they were generally needed only for one household member, the premium was higher (100 Z per month) so that the cards wcre more affordable, and getting photographs made and developed is relatively straightforward in Kinshasa. In Bwamanda, identification photographs would have cost as much as the insurance. Instead, control relies on identifying information about the insured. First, his health card contains some descriptive data about the person named (age and height) that can be matched against his or her appearance. In addition, the enrollment register contained the names and birth dates of other family members about which the presumed insured can be quizzed. (d) Assuring that the policy of enrolling all members of the family is enforced. In Bwamanda, as in some other zones, the health centers endeavored to maintain up-to-date cards on all persons in their catchment area. Provided that these cards were up to date, they create a roster for each family at the time of enrollment. (e) Assuring that patients and insurers are charged appropriately for services through a clcar system of prices. In Bwamanda, hospital care was charged in one of 16 all-inclusive prices per admission. This simplicity reduces the risk that the provider will perform unnecessary services to overcharge the insurer. 5. Appropriate Investment Strategies Can Prescrve the Value of Premium Income over the Year Because of the high rates of inflation in Zaire, the operation of insurance poses special challenges. In other countries, premium income could be kept in cash from the beginning of the year, when it is <-llected, until the middle of the year, when it is spent. In Zaire, where the rate of inflation may exceed 100% per year, this approach would be ruinous. Approaches to saving money without major erosion by inflation include investing in a responsible local institution. For example, funds invested with the CDI at Bwamanda earned a compound rate of 2.5 percent per month in 1989 (34.5% effective annual yield). It may also be possible to invest in drug supplies, provided the pharmacy is well run and drugs are safe. As drugs are mostly imported, their value will grow in proportion to the exchange rate with their country of origin. 6. Financial Analysis of the Insurance System Requires Better Accounts None of the insurance systems visited by the team had up-to-date financial statements for 58 the system that could be used to assess its financial health. In CASOP, the financial system was so incomplete that no financial statement could be constructed for either the polyclinic or the insurance system. In Bokoro and St. Alphonse, financial statements for the health centers could be constructed, but premium income and expenses of insured patients could not be separated from the centers' other financial transactions. Bwamanda constructed an annual financial statement for the insurance plan at the end of each year, but it contained so many year end journal entries that no meaningful analysis could be performed mid-year. Better financial accounts would aid the insurance systems in setting premiums and controlling costs, as well as providing better data to guide future policies. 7. A Financial Guarantor Can Help Build Confidence in Launching an Insurance System When a new insurance system is established, many factors could precipitate insolvency. Accumulated health problems could lead to an initial burst of demand. Inadequate data or limited information could lead to underestimation of utilization or prices. An insurance plan may incur fixed expenses despite low enrollment. The public will be more likely to enroll in an insurance system if they are protected against these outcomes. Many organizations could serve as a financial guarantor. In Bwamanda, the CDI served this role. (Fortunately, it was never required to make good on its guarantee.) In the future in Zaire, this study encourages existing organizations to serve as guarantor. The Government of Zaire, with support of PASS, the SANRU program, Sante Pour Tous, UNICEF, or a PVO might serve this role. The financial guarantee need only be given for one year at a time. If there are losses, the premiums or services can be revised or, if necessary, the system can be abandoned to prevent further losses. C. RESOURCE MOBILIZATION 1. Access and Resource Mobilization Motivated Health Insurance Schemes Health insurance systems were started primarily to meet two objectives concurrently: mobilizing resources and increasing access to services. In the health zones of Bwamanda and Bokoro, the hospitals had chronic or mounting deficits. They felt that substantial increases in user fees would price their services beyond the ability of the population to pay. With health insurance, ill persons would be more likely to seek care. As evidence of the goal of increasing access to health services, the insurance systems were promoted by developmental organizations such as the Center for Integrated Development in Bwamanda, the Development Committee of St. Alphonse Parish in Kinshasa, and the social welfare structure of CASOP. In Bwamanda, where the most detailed financial statements were available, the share of the hospital's operating costs recovered rose from 48% in 1985 to 79% in 1988. D. UTILIZATION AND ACCESS 1. Evidence of Adverse Selection and Moral Hazard was Found, But Plans Minimized Their Impact In every plan for which utilization of insured and uninsured persons could be compared, insured persons were found to use more services. In Bwamanda, insured persons were 6.7 times as likely as uninsured to be hospitalized. At Bekoro health center, plan subscribers had 5.0 times as many new ambulatory episode as non-subscribers. In the Kinshasa surveys, insured respondents reported more previous visits (2.0) for their current illness episode than uninsured (1.6). Similarly, utilization data from CASOP showed more visits per episode among individuals insured (2.5) than among those uninsured (2.0). While comparisons among the diverse insurance plans require caution, this evidence suggests 59 that insurance makes a big difference in the likelihood of receiving services at all, but has only a modest impact on the intensity of those services among those receiving some care. Plans used several approaches to minimize risk of adverse selection. Several required family membership. In Bwamanda, Bokoro, CASOP, SNHR, and now Masisi, if one member of a family joins, then the family must join. In REMEF, St. Alphonse, and formerly in Masisi, there was no such requirement. (Policies for UPM were not known.) This policy seemed to be effective in increasing enrollment overall, and members without special risk specifically. As plans did not graduate premiums by age or prior illness, the risk of adverse selection could otherwise be substantial. Masisi found that in its first six months of operation, enrollment was low and a deficit was incurred and the zone has therefore changed to family enrollment. Other plans enrolled employee groups. Employee groups constituted 100% of members in Bokoro and 80 percent in REMEF. In CASOP, although the share of company member is unknown, they accounted for 51% of visits in 1989. SNHR is also an employee group and UPM is sponsored by workers' unions. This strategy appears successful in helping to make the insurance plan viable and should be encouraged as one method of recruiting members. It should not, however, be the exclusive method of enrollment, as that policy would exclude the bulk of the rural population. In Bwamanda rural health zone, for example, only 4.6 percent of the population was employees or their family members. Some plans limited enrollment to a specified time of the year. In Bwamanda, enrollment took place only in March to April, after the second harvest. In St. Alphonse and CASOP, enrollment was allowed at any time of the year, and in CASOP, even when the subscriber was ill. Policies to limit adverse selection are most important when adverse selection would be most severe. This would occur when insured individuals would receive substantial discounts on infrequent, expensive services. Thus, limiting the time of enroliment or restricting enrollment at the time of illness is important in Bwamanda, where the insurance covered inpatient care and chronic illness, and in the CASOP. 2. Systems of Utilization and Cost Control Can Help Make Insurance Affordable Several systems of utilization and cost control have helped to make insurance affordable. Co-payments have been used by all of the systems visited. In Bwamanda, the user generally pays 20%; in Bokoro, 25%. In St. Alphonse and the CASOP, the payment schedules are more complex, but co-payments average about two thirds of the costs. Previously, when CASOP had no co-payments, they found that outpatient costs far exceeded the share of membership fees available to cover them, and the policy was changed. Plans have also excluded certain services in an effort to control costs. The Bokoro subscription does not pay for ambulatory care of chronic illnesses. The Bwamanda insurance does not cover initial ambulatory consultations directly with the physician. Bwamanda used another important device to control cost: utilization control, through insistence on the referral system. Before a patient could be hospitalized, the patient had to be referred from a health center and a provider at the hospital had to confirm the need for admission. E. INFORMAL ASSOCIATIONS 1. Informal Associations Financed Health Care Only Through Emergency Loan Funds There are two types of informal associations. In a likelemba, or rotating savings association, each participant contributes a specified amount at a designated frequency. Among the participants surveyed in this study, the contribution averaged $ 47.91 per month. One member receives the entire pool at each interval. Members used the savings for business investment, 60 purchase of a household durable good, or schooling. None said that they saved for medical expenses. In a moziki, members not only make periodic savings into a pool, but also contribute regularly into an emergency loan fund. The pool financed loans to members in cases of births, deaths, marriages, or hospitalizations. In a survey of 54 moziki members, 10 had received loans in the past year, of which 4 were related to health (births or hospitalizations). Borrowers repaid loans without interest. In two moziki, members facing extreme difficulties could request a special collection from which the proceeds were given, not loaned, to the member in need. F. STRENGTHENING EXISTING INSURANCE SYSTEMS The existing insurance systems, while vibrant and innovative, could benefit from several steps. 1. Training Training in the basic concepts and administrative aspects of health insurance schemes should be offered at the School of Public Health, University of Kinshasa, at successfully functioning systems such as Bwamanda, and through refresher programs offered by FONAIMES, SANRU and the Sante Pour Tous project. A manual about the management of health insurance plans should be developed for this training. The training should consider both general principles (how to calculate premiums based on actuarial data) and an analysis of the experiences of functioning plans in Zaire. 2. Exchange Visits An intra zone program of staff exchanges or site visits should be established. The existing systems could invite personnel from nearby zones to observe their system and adapt their forms and procedures. For example, under the sponsorship of officials for Equateur Region, the health zones around Bwamanda (e.g. Tandala and Gemena) could be given assistance in adapting and replicating the Bwamanda system. 3. Information Systems Without a standardized information system and monitoring procedures, the costs and benefits of a health insurance system are difficult to evaluate and almost impossible to compare with other plans. To help existing insurance systems and possible future efforts, an appropriate coordinating agency (SANRU, PASS, or the Ministry of Health) should develop guidelines for information collection which would assure that utilization and accounting data are adequate for evaluation purposes (for example, availability of utilization and financial data by major payment categories: insured, employed, uninsured and unemployed). Data analysis was hindered by the fact that none of the plans appeared to have a unique identifying number for each member. With decentralized enrollment through health centers in Bokoro and Bwamanda, each health center tended to develop its own numbering system. A comprehensive system would be easy to develop, in which the first digits represented the health center, the middle digits the village and the family, and the last digits the individual. 4. Technical Assistance Technical assistance can help each plan tailor the lessons learned from the three areas above to their own site, and to implement new accounting systems or policy changes. 61 G. ESTABLISHMNT OF ADDITIONAL INSUJRANCE SYSTEMS 1. Rural Health Insurance Systems This study suggests that insurance systems have increased access to health services and mobilized resources in rural areas. Thus, a policy goal is to foster the development of additional systems to serve other parts of the country, and to gain more experience as to which approaches work best in which situations. The study suggests that additional rural schemes be established building on the lessons learned. This study suggests initiating varied types of systems: some for inpatient care only (like Bwamanda), some for inpatient and outpatient curative care (like the intention for Bokoro), and others that are comprehensive and include preventive services as well (like REMEF). Th training, site visits, information systems, and technical assistance recommended above to strengthen existing systems should be extended to encturage new rural systems. A model of particular interest for ambulatory care would be a system of prepayment. A member would prepay for a specified number ot .mbulatory episodes; say, five. He would receive a book of five vouchers. The subscriber % uld be offered a discount compared to the current charge in return for having prepaid the services. The vouchers would be prc.inoted for sale, like insurance, at a time of the year when cash was most available. 2. Urban Health Insurance Systems The Chief of the Commission on the Organization of Mutuals had been invited to submit a recommendation for consideration by the government for an urban hased health insurance system. Any urban based systern is likely to experience high utilization and, perhaps, expectations for high quality. This study suggests that a hospital-based HMO-type insurance plan should be tested. Civil servants and their families would enroll on a family basis, paying a set premium which would enable them to seek inpatient care in case of need at a specified hospital. A separate organization would manage marketing efforts for the plan, and would turn over a percentage of the premium payment to the hospitals, based on subscribers. The premium would be set high enough to cover the risk of adverse selection. Users would pay a co-payment for each episode of hospital care. Ambulatory care could be controlled either through co-payments or through a voucher system, like that described above. The potential advantage of this approach is that it includes mechanisms to direct hospital use to a particular facility and to control utilization. Utilization rates should be projected initially based on the experience of other large employers with similar workers; the system should then be refined based on actual experience. 62 REFERENCES 1. World Bank. Zaire: Ponulation. Health and Nutrition Sector Review. Population and Human Resources Division, Africa 111. Report No. 7013-ZR. Washington, D.C. May 15, 1989. 2. Mills, Anne. 'Economic aspects of health insurance,' in The Economics of Health in Develoginj Countries- eds. Kenneth Lee and Anne Mills. New York. Oxford University Press. 1983. 3. Baer, Franklin C., 'The Role of the Church in Managing Primary Health Care in Zaire," USAID Kinshasa, Zaire: SANRU Basic Rural Health Project. No Date. 4. Bitran, R., et al. 'Health Zones Financing Study, Zaire.' Report prepared for the Resources for Child Health Project, USAID. Arlington, VA. March 1987. S. Bitran, R. 'Zaire Social Sectors Adjustment Project Health Care Financing Report." Cambridge, MA: Abt Associates Inc. for the World Bank. March 29, 1989. 6. de Bethune, X., Alfani S. and Lahaye J.P. 'The influence of an abrupt price increase on health services utilization: evidence from Zaire.' Research Reports. WHO, p. 76- 81. 7. Bitran, R., 'A '986 Update of the Zaire Health Zones Financing Study.' Report prepared for the Resources for Child Health Project, USAID. Arlington, VA. April 1988. S. Bitran, R., 'A Household Health Care Demand Study in the Bokoro and Kisantu Zones of Zaire: Volume II: Descriptive Analysis.' Report prepared for the Resources for Child Health Project, USAID. Arlington, VA. Draft, Sept. 1988. 9. Bitran, R., et. al. 'Case Studies on Management of Ten Health Zones in Zaire.' Report prepared for the Resources for Child Health Project, USAID. Arlington, VA. 1986. 10. Bittan, R. A. 'A Supply-Demand Model of Health Care Financing.' Report prepared for the Resources for Child Health Project, Basic Rural Health Project, and Economic Development Institute of the World Bank. Draft. Cambridge, MA: Abt Associates, Oct., 1989. 11. Dikassa Lusamba, et. al. 'Community Financing for Primary Health Care in th. Republic of Zaire.' Chevy Chase, MD: Primary Health Care Operations Research Project (PRICOR) 1986. 12. Ebenga Lombilo. L'Assurance-maiadie via ia solidarite sociale nationale: comment atteindre cet obiectif au Zaire? Dissertation pour l'obtention du grade de licence speciale du departement des sciences hospitalieres et medico-sociales a Bruxelles. Bruxelles: Universite Catholique de Louvain, Faculte de Medecine. 1988. 13. Ebeinga Lombilo. Mission d'Oruanisation des Mutualites au Zaire. (Rapport Final). Conseil Executif. Kinshasa, Zaire. Sept. 1989. 14. Moens, F. Design. ImoleMentat and Evaluation of a Community Financin^ Scheme fgr Hospital Care in DeveIoni0 untries: A Pregaid Health Plan in the Bwamanda Health Zone. Zaire. Thesis pr op.. -or completion of Master of Public Health degree at the University of North Caroitu- at Chapel Hill. 1988. 63 15. Vian, T. et al. 'Financial Management Information Systems in Four Zairian Health Zones.' Report prepared for the Resources for Child Health Project. Arlington,VA. December 1987. 16. Vian, T. 'A Household Health Care Demand Study in the Bokoro and Kisantu Zones of Zaire: Volume I, Survey Design and Data Collection Techniques.' Report prepared for the Resources for Child Health Project. Arlington, VA. June, 1989. 17. de Ferranti, D. 'Paying for Health Services in Developing Countries: An Overview.' Staff Working Paper No. 721. Washington, D.C.: Worla Bank. 1985. '8. Griffin, C. 'User Charges for Health Care in Principle and Practice." EDI Seminar Paper No. 37. Washington, D.C.: World Bank. 1988. 19. World Bank. 'Financing Hcalth Services in Developing Countries: An Agenda for Reform.' Washington D.C., World Bank. 1987. 20. Vogel, R. 'Cost Recovery in the Health Care Sector: Selected Country Studies in West Africa.' World Bank Technical Paper No. 82. Washington, D.C.: World Bank. 1988. 21. Karaha Kagobo, Kagado Musinda Rweju. Le 'likelemba' ou forme d'association en mileux urbains,' "(insha.a(a Zairian magazine), p. 11-12, 1988. 22. Marx, hi 'Social Sector Adjustment Credit (SSAC) Cooperatives d'Epargne et de Credit.' Report prepared for the World Bank. Kinshasa: J.G.P. Consultants. July 1989. 23. RaDDort Annual. Zone de Sante Rurale de Bwamanda, Zaire. 1985, 1986, 1988. 24. Shepard, D.S. and Benjamin, E.R. 'User Fees and Health Financing in Developing Countries: Mobilizing Financial Resources for Health.' Ir Health. Nutrition and Econornic Crises: Aovroaches to Policy in the Third World Bell, D.E. and Reich, M.R., eds., Dover, MA: Auburn House Publishing, 1988. 64 ANNEXES ANNEX I Description of the Zaire Health Zone Structure And Managem^nt Organization ............................................. 66 ANNEX II List of Prices 1988 and 1989 Bwamanda Reference Hospital and Health Centers ............ ............................... 71 ANNEX III Exchange and Inflation Rates ............................... 74 ANNEX IV Documentation for Bwamanda Health Insurance Plan .... ....... 75 ANNEX V Survey Questionnaires and Resolution of Ambiguous Data ....... 79 65 ANNEX I Description of the Zaire Health Zone Structure And Management Organization * Source: Adapted from Bitran, et. al. 'Health Zones Financing Study" 1986, with some edits. 66 Administrative Structure of the Zones and Managemnt Systems This appendix describes the organization of the facilities that belong to the zones' networks. The Zairian health zones are organized according to the classical pyramidal model (see Figure 1). At the top of the set of providers is the set of providers is the reference hospital which provides mostly inpatient care and deals with more complicated health problems. At the bottom of the system are the health posts which treat more simple, ambulatory cases, and promote preventive programs. Health centers and reference health centers are in intermediate levels and provide a mix of ambulatory and inpatient services. Linking these four levels of health care units is a system of referrals. Patients who canaot be treated at a given level due to the complexity of their problem are sent to the level about to seek treatment. The medical and administrative activities of these four categories of health care units are supervised and coordinated to varying extents by the zone's central office. The nature of the relationships between the above-mentioned units varies among the zones. Decisions at the health zone level are usually made by the health zone management committee, usually presided over by the Medecin Chef de Zone. Providers, health centers, the reference hospital and the population are usually represented in this committee. Decisions concerning the set of health centers are usually made at the health centers' management committee, where the population, providers, and health centers' technical personnel are represented. The Medecin Chef de Zone normally chairs this committee. Technical and administrative activities of the ref:rence hospital are usually decided and coordinated by the hospital management committee, co-chaired by the hospital director and the Medecin Chef de Zone. The population plays an active role at the health center level through the health centers health committees. Usually, each health center has its own committee made of community volunteers. They play a major role in controlling the health center's accounting, and are essential at promoting activities such as health education and sanitation. The central office supervises the medical and administrative activitics that take place in the health centers. Supervision involves periodic trips to the facilities by the Medecin Chef de Zone and other doctors and nurses of the central office. In exchange for its supervisory services, the central office charges a fee to the health centers. The supervision fee may be the same for all health centers or may vary depending on the volume of activities of each individual facility. for example, in Kalonda, each health center paid a monthly supervision fee of 400% in 1985. In Kirotshe they paid 10% of their monthly revenue, excluding that from the sale of drugs. In Dungu in 1986, health centers pay to the central office 50% of their monthly revenue, drugs excluded. Finally, in Bokoro, the supervision fee paid by each center is proportional to the population of the center's health area and to the number of new curative cases treated in the facility. In addition to its supervisory role, the central office performs a series of other activities which permit the functioning of the zone's health network. The other activities include accounting, financial and technical planning, drugs and material purchasing and management, training of the zone's employees and coordination of immunization activities. The supervision fees are generally insufficient to finance the expenses attributable to that activity and are only a small fraction of the central office's total expenses. 67 Figure 1 Administrative Structure of a Health Zone Medecin chef Health Zone de z ne (MCZ) Hospital _ Management Director Committee _ _ Hospital Health Centers Central Management Management of fice Commit tee Commlttee Reference Technical Hosoltal Supervislon R E F Management R Coin Ittees Control A A L Reference D Health Drug Center Supply R E F E Health R Committees R A L Health Centers C__ _ R E F Health E Comr ittees R A A L Health t Posts 68 With regard to the supply of materials, health centers purchase the majority of their drugs and medical supplies from a central pharmacy which is usually managed by the central office. In some zones the central office changes the health centers a mark-up above purchase price which helps finance its operating costs. In other zones, the office acts only as an intermediary and does not charge any fee for its role of supplier. The proportion of drugs and materials that the health centers purchase from other local suppliers is usually small. The major relationship between health centers and the hospital is the referral of patients. In most cases, patients are referred to the hospital at no cost to the health center. In a few cases, however, health centers do have to pay a fee to the hospital for each referral. Such a fee is set by the hospital to discourage health centers from referring patients whose health problems can be treated at the health center level. In Kikimi, such a payment was SZ in 1985, which obviously did not cover the costs generated by the referred patient. Kindu is another example of a zone where the health centers have to pay the hospital for referred cases. In 1985, the hospital received 75,900Z ($1,500) worth of referral fees. Finally, the reference hospital is intended to be a financially independent unit and its only formal relationship with the central office is, in most cases, the purchase of drugs. 69 ANNEX n LIST OF PRICES 1988 AND 1989 BWAMANDA REFERENCE HOSPITAL AND HEALTH CENTERS M0Ld" MJ 6 . M A04WAd "- " 4. NOPZL MMUL DE REF=C TAB W>S D SO2NS 3ICAUX A LIOPIThL WJMAYA A PARTR DU Z7/04/1989 No DEIMIATI Dr SOXNS |CA. CATROO R I E _A* So DQRE DE V ON RECENSE *=3UMLE RMSE S0CS OS ?6diatris I 1.500 s 300 s 3.000 s 3.750 s 02 P4dLtriLe U (boins z tumasifu) 2,500 a 500 * 5.000 a 6,250 a 03 Xdectiao Intere I (Ambulatoire) 3,000 s 600 s 6.000 u 7.500 a 04 X6docino Interne U1 (Hosp1tcllgat°2 4.500 a 900 a 9.000 s £1,250 5 0-5 X6doo1ue Intenme III (S. ntemsifoj 6.500 s 1.300 s 13*000 a 16.250 s 06 C4iwgio I 3.500 . 700s 7.000 a 8,750 a 07 trirzio s1 7.000 a I,400. 14,000 5 27.500 s 08 Cirurgie III 8,500 a 1700 s 17,000 s 22.250 s "09 0hMiazrge Iv (ur6ence) 10,000 s 2.000 s 209000 a 259000 s - £0 hteoiiite avee C,oPN. 1,500 z a r ia u It 3.000 a 3,750 a . Mte±stEf safs C.P.e. 4.500 a 4*500 s 9,000 s 1Z1250 s £2 Oa6colgde ° 4,500 : 9005 9,000 s 11S250 5i S3 34.U44. ohTm±ques +T3C lb 1Lge 2,000 a .400 s 4,000 S 5,000 S E4 TBC 2frn lgne 5,000 s 1.000 s 10,000 121.500 £ Ext5 taction dentairo + Cireonco1aon 1.000 . 200 s 2.000 a 2.500 s 16 0ormiltation Privie at Esmcn. * I d: ptltaue epbgsioque 3.000 a. 3.000 a 3.000 a 7.500 5 0CSUVAT120NS I* L'soeoucohmux* cut gatudt pour lee fa.on qu± ant szu1v le" C.P.N e t quA sont mambres de ls gutuel.-_ 2. Caabre ftUvil e1le s 250 . 3. riz t'.'A ffllation (Xutiello) I 125 S/an ISIt & JSWl&02 15/04/989 1001 &Es0W. DI031 DI L& 03 DM SANTE PURAIZ WWL 70 * Da. FPDZl01rVS I . K6decn-Qaf 4.ome Tarif des sois sedicaux a partir du 15 gvril 1989 ,*** W4. aibId I .*.I.iLL. U. 1uJgAM#II%IIUA CDI - 8WAMANDA 0.P. 11 CEMENA. TAItIF OES SOINS ME3ICAUX AUX CENTRES OE SANTE A PARTIR OU 15 AVRIL 1989. C A T E C O R I E OESIGNATIOtJ uE SOIN5 EC T E S R Rocons6as N. Roe. 01. Consultat0 Enfant t Eleve 200 z. 400 600 z 1.000 z 02. Consultation adulte 400 z 800 z f 1.000 z 2.000 z 03. Consultation Pr4natale + Nzissance d4sirable j 400 z 400 Z 400z400 z 04. Consultation gr6scolaire 200 z 200 z l 200 z 200 z 05. Fiches familioles I G R A T U I T 06. Carts de recensoment 1 20 Z 07. Pharmacis famili2le (sa- I chet nivaquine + aspirine) I z 08|O Vente condom p e 10 4 0o. .Mladies chroniqucs 2000 z.& 4000 Z 5000 z i 10.000 I | " ~Los membres du la mutuelle Payent 400 z I ~~~~~~ - I_ OEt,W01VATIONS: • Les fruls de traitement de maladies chroniques no couvrent pas lis au- tres episode de maladies . • Los malades Cont l'6tat nicessitO uns ficho d'hospitalisotion au Centre de 5ant6 do :Rof6rence (transfusion9perfusion,tr:Ltement filairo,...) payOnt une dauxi6me quittance, Falt a Swomanda.le 13/Avril/1889 POUR LE COIMTE DE CESTION OZ LA ZONE DE SANTZA RURALE DE 0WAMANDA OR, FREODtY MODENS t16docin-Chof de Zone. 71 Tarif des soins medicaux a I'hopital a partir ler fevrier 88 ZONE DE SANTE HUIJ1LL EJL L.JuiM0NUM HOPITAL GENERAL DE REFERENCE 8.P. 11 GEMENA TARIF DES SOINS MEDICAUX A L'HOPITAL GENERAL OE REFERENCE DE BWAMANOA A PARTIR OU let FEVRIER 88t C*XNXUXSX--x-XBx DESIGNATION DE SOINS C A T E G O R I E Recens6 Membre de l Mutuulle N.Rec; Soci6t i.(2 3)12.(10%) 3.(S%) |01. Pediatrie 600 z 120 z 10 Z 30 z 1.200 1.600 02. Midocine Interne Am ul1000 z 200 z Z SO z 2.000 3.000 03. Mtdecine Interne hOSp, 100 Z 350 zt 20 z 100 z 3.600 4.800 IC4. Gymttcologie 1800 z 3SO z 160 a 100 2 3.600 4.800 OS. Maternit6 avec CPN SOO z G ri a t u 11 t 1.000 2.000 06. Materniti sans CPN t500 z 1.500 2 1500 SSOO z 3,000 4.500 07, Chirurgie I 1000 : 200 Z t30 z SO0 z 2.000 3.000 oe. Chirurgie II 2500 z SOO z!2S0 2 120 z 4.000 6.000 09, Chirurgie III 3000 z 600 z 300 z 150 z S.000 7.000 10. Chirurgie Iv (ur:ence) 3500 z 700 'z 350 z I180 z 6.000 a.000 II. TSC + malaoies chron. 750 z <-_-- ISO z -------- 1.500 2.200 12. TGC 2eme ligne 11500 z _------- 300 z -------t 3.000 4.500 13. Consultations ,:rvc5s 11200 z E---fl200 z -------- 1.200 2.500 2Q1ERMAI0NS: 1. Pour lcs femmes ayent suivi les Consultations Pr6-Natales, liaccouchement *st gratuit i condition d'ttre membre de la Mutuelle. 2, La circoncision cst gratuite pour Is bib6 Clune semaine. Au-061i de cet tge,10 tarif de la p6oiatri otst d'eoplice- h;1 c I . 3, Chamnrc priv6e: ZOO z/Jour. L tL,XurO I :Centrcs ce Sant6 axe ISA8E-M9ARI CLounc 2:Centras do Sant6 dc: Boto-Kassongo-9ombis-BOVaZi- - Songbads et Booamo . ' rouou 3:Ccntes die Sant6 de: Bobandu-Solumbc-9aowara-Bobisi 9ombisao-owskara-Sombilii Fait a Bwsmanda,le 24 Janv.1988 POUR LE COMITE D0 L.r.T1Ctj r) LA POUR LES ADMINISTRATEURS ZONE DE SA'JTE DU w1rnfJDA DU CDT - BWAMArDA AsOl 5 '! : EL2 BETYNA NGILASE GOELE - DOLO A0MItJISTRATEUR-CHEP0E PR0ET Tarif des soins medicaux aux centres de unte a partir ler fevrier 88 REPUBLIOUE DU ZAIRE ZONE DE SANTE RURALE DE OWAMANDA CDS- eWAMANOA 9P*. t1 GECENA- TARIF DES SOINS MEOICAUX AUX CENTRES DE SANTE A PARTIR U 01.ir FEVRIER 88S UK- XUXUU- x- ZxUEUxMxSx-xx C A T E G O R I t DESIGNATION DE SOINS - __Rens________ _QCIE_Recen 6 '.R c ns6SOC Recens_ es_ N. R9ecen. 01. Consultation Enfant+Elive 100,- z 200,- 2 200,- a 400,- z 02. Consultation Aaulte 200,- z 400,- 2 400,- 2 600.- Z 03. Consultations Pr6natales + Naissances d6sirables 200,- z 200,- z 200,- z 200,- z 14. Consultations Pr6scolairos 100o- z 100o- z| iao,- z 100,- z OS. Fiches familialos G R A T U I T 06. Carte Rocenccment -------- -------- i z …----------… ;07. Pharmacie Familialo … ----------------- 20,jO z - …----------- (sachet nivocuine/aspirini) Sachot SPO,Condom ----------------- 20,00 2 -- ---- - - - 08. Maladie chronique C A T E G O R I E Recense imemore de la mu, hon,Rec SOCtETES R tuelle Rec N.Rec. 750,- z. 150,o z s1o00 !150 000, 0OSERVAT!CNS: • Los frais dx traitumcnt do maladies chroniques no couvrent pas les autres 6pisodos do m:;5Idius. • I.es moloccs cr.t 1'1tat n6ccssito une fiche d'hospitalisation au Centra de Sant6 me n6f6r.nne (transfusion,purfusion,traitement filsire...) payent une deuxijmc quittonce. Falt 6 Bwamenda,le 24 Janv.1988 POUR LE COMITE DE CESTrON DCE LA POUR LES ADMINISTRATEURS ZONE OC SANTE nRUALE OWAMANDA DU COI - SWAMANDA Asbl OR, vAnT CnICL BETYNA NOILASE GeELE - DOLO Mr.FDECIN-C,r Cr. ZC¶E AOMINISTRATEUR-CHCF DE PROJET 73 ANNEX Ill EXCHANGE AND INFLATION RATES Average Annual Inflation Rates in Zaire 1985 30.6% 1986 46.0% 1987 79.0% 1988 113.8% 1989 37.3%0 11989 is an 8 month average, Jan.-Aug. Source:1985: Zaire Ponulation. Health and Nutrition Segtor Revige. Report No. 7013-ZR, World Bank, May 15, 1989. 1986: World Bank Office in Washington, D.C. 1987-1989: World Bank Office in Kinshasa, Zaire Average Annual Exchange Raltes: Zaires to US Daollars and Belgian Francs $1 U.S. I BF 1986 61.0 1.6 1987 128.3 3.8 1988 187.0 5.1 1989 354.2 8.9 (Average for 8 months, Jan.-Aug.) Nov. 89 430.0 Source: 1986: World Bank Office, Washington, D.C. 1987-1989: World Bank Office in Kinshasa, Zaire 74 ANNEX IV DOCUMENTATION FOR BWAMANDA HEALTH INSURANCE PLAN 1. Control Sheets for Stock of Membershin Stamns Control sheets are filled out in duplicate, with one copy kept by the administrator and one copy kept at the health center. Each time the health zone administrator makes a control visit to the health center during the inscription period, he updates both copies of the control form. The health center nurse then signs the copy kept by the administrator, and the administrator signs the copy kept by the health center nurse. Example: IOuent. |Ouant. Iouant.| lRemnIn I I DateIRecv'dJStock IValue ISold IValuel der Ivalue ISIfoture ................................................................ 27/211,000 11.000 11250001 -- I I 1.000 11250001 ................................................................ 07/31 ... I - I -- 1193 1247501 802 11002501 14/31 300 11,102 11377501 426 1532501 676 1 845001 , ........................................................... 2. Membershig Register for Bwamanda InsurancePan As each member pays the inscription price, the health center nurse registers the new member in a registration notebook, organized by village. In the sample register page shown below, three numbers are assigned to each member. The first number ("Cen.") is the census number, given to each household during the medical census. The second number ("Order") is a sequential number given to each individual who joins the plan from a given village. Thus, there is a membership number P" for each village. The thira number is a number given to each family, again sequential within each village. The lack of unique membership numbers is an impediment to data analysis and evaluation of the insurance plan. The field for 'family composition' shows the individual's position in the family, e.g. "F" for father, 'WI' for first wife, 'W2" for second wife, 'C" for child, etc. The field for 'attendance at the hospital" indicates the date of hospitalization and the service where the member was hospitalized (for example, MLIA' is Internal Medicine, Ambulatory). Exmp.: ~,. ................................ .... ...... No. I No. I I Fmtly | Old | Atten- -------------.I f- I I I Cowp- mb. daoce Can. I Order I lty I 1i_e I Age I os.tfoni Numberl at hosp. ................................................................ 35 | 1 1 1 Yutonego | 6O yrl F 1 35 | 2 1 1 K ea I SO yrl WI I 35 I 3 w 19 yrano g. 9y I C | 4 § | Yuku 47yrl W2 l 25 | 5 2 | Soongs |29 yrl F | 25 1 18/9 MIA ................................................................ 75 3. HosDitalizat;on Notebook Another important source of information about hospitalized patients is the hospita:ization notebook (Cahier d'hospitalisation), filled out at the hospital admitting/billing office, when the patient registers. The notebook contains the patient's name, village, sex, date of hospitalization, hospital service, amount paid, and three identification numbers. The first ID number is a unique, sequential patient number. The second number is the census number from the household medical census. The third number is the insurance plan membership number, where the patient is a member of the Bwamanda Insurance Plan. A separate hospitalization notebook is kept for the maternity service. 4. Billinz After having paid the hospitalization fee, patients receive a receipt, which is stapled to the medical record, as proof of payment. Different color receipts are used for each payor category. A second copy of the receipt is kept in a receipt book at the admitting/billing office and used to calculate total receipts by payor category at the end of each day. If a patient cannot pay the full price of a hospitalization, the patient may still be admitted if he or she can afford at least half of the hospitalization fee (it is rare that patients arrive at the hospital with less than half of the fee). A special 'Advances' notebook is kept to register the payments of patients who cannot pay the full amount at the time of hospitalization. The procedures for collection of the remainder of the fee, once a patient has been hospitalized, are ad hoc. The responsibility usually falls to the nursing staff to get the patient to pay the remainder of his or her account. Hospital accounting procedures do not capture free care or bad debt, so these expenses are not reported in the hospital financial statements. 5. Financial Records and Reoorts for Insurance Plan Two forms are attached which are used for recording financial information about the Bwamanda Insurance Plan. The first form ("Releve Mensuel Mutuelle 19..') is used to record monthly hospital and health center charge3 incurred for members of the insurance plan. The second form ("Situation Mutuelle 1988" -- also used for 1989) records all financial transactions (deposits, withdrawals, interest payments). Usually one line is used per month. The form is being revised, currently, to increase flexibility in recording transfers of funds. 76 Releve Meusuel Z.S.R. - bWAMANOA B.P, 11 GNA RELEVE NENSUEL MUTUELLE 10... _____________________ me. o_ ___________ .... . HOPITAL GENERAL DE REFERENCE 9WAMANOA _ CENTRES DE SANTE NOI DESIGNATIONS GROUPE NOMBRE! MONTANT NI re Tot N/CENTRE 01lPEOIATRIE I I X** |sl.XAS ?2 1 2 .5..x !t i. . .. 'xi 9o | | §,/Totol: AtS ..=fl .... 1 * . .. !02 CHIRURGIE z ........ ~~~~I |ISI j .XZ.... Z ....... ! S/Total I 03i IC,IRURCIE 2 .... z I S/Total ........ - - _. _ _ _ .......z; II X..,z, ...Zi 06 CHIRURGIE 3 I S/Total: " ' i" ' *w *- *.i s 1- -- -- I - - , *~~~-g----------- s-- 05 CHIRURGIE 4 Lon IIf.G4....AZAIl 'III ,x ,z ,, z ~ProportonAfit .._ S/TotFF ' j per group I ~~~~~~ ~~~~~~~~Total; . ... MEDECINE INTER-J I X.. . ... Gul... I 06!NE AMflBUt.ATIRE II ,.X ... Z S/TotOl **II d GrouPe 3:.... 0 MEDECINE INTER-; II *.X.**z ... Z °NE H.?QPJTALISA-I III I X..Z| *.Z S/Total : / / I / / OICGYNECOLOGIE Is ..x...z i S ! ' ~~~~~~~~S/Total 7 / , I;9 1ATERNITE X ... I 10Tc: lire ligne . .. I !-* I i I I IIITOC: 2imS lignm .. TOTAL I * - -- w i I |TOTAL GEN.(HGR R CoS.) /-7 77 Situation Mutuelle ZONE DE SANTE RURALE DE SWAMANDA S.P. 11 CEMENA REPUELIOUE DU ZAIRE- SITUAT.ON Ml JELLE 195d -- , - - - - i * ~~~~~~~RLMUOURSEL PERIODE REPORT RETRAITS CAPITAL INTERE MONTANT| MENT.. OTAL 19e8 198 7 | DEeUT PER , 3% CAPITALIA HMRC, S. .. . _ . .T _ . __-_I ...~~~~ --1_.*, . . ~ ~ _ __ _ _I I I _ __ __ I ___ _ _ _ _ . _ _ _ _ _ _ _ _ _ _ _ _ _ ___ ,_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ I j_1- ' _' _ - i_I M __~__ --!____ - - 78 PRE Working Paper Series Contact ALg1QAhor for paper WPS469 Modeling Economic Behavior in J. Barry Smith August 1990 M. Abundo Peru's Informal Urban Retail Sector Morton Stelcner 36820 WPS470 What Do Alternative Measures of Alexander J. Yeats August 1990 J. Epps Comparative Advantage Reveal 33710 About the Composition of Developing Countries' Exports? WPS471 The Determinants of Farm Gershon Feder August 1990 C. Spooner Investment and Residential Lawrence J. Lau 30464 Construction in Post-Reform China Justin Lin Xiaopeng Luo WPS472 Gains in the Educatior, ot Peruvian Elizabeth M. King August 1990 C. Cristobal Wome ., 1940 to 1980 Rosemary Bellew 33640 WPS473 Adjustment, Investment, and the Riccardo Faini August 1990 R. Sugui Real Exchange Rate in Developing Jaime de Melo 37951 Countries WPS474 Methods for Measuring the Effect Anne Maasland August 1990 P. Dixon of Adjustment Policies on Income 39175 Distribution WPS475 Does Divestiture Matter? A Ahmed Galal August1990 G. Orraca-Tetteh Framework tor Learning from Experience 37646 WPS476 Health Insura _e in Sub-Saharan Ronald J. Vogel August 1990 K. Brown Africa: A Survey 3nd Analysis 35073 WPS477 Private Participation in the Delivery Thelma A. Triche August 1990 M. Dhokai of Guinea's W;ater Supply Services 33970 WPS478 InterreIations Among Child Mortality, John Marcotte August 1990 S. Cochrane Breastfeeding. and Fertility in John B. Casterline 33222 Egypt, 1975-80 WPS4 79 Conversion Factors: A Discussion Michael Hee August 1990 E. Zamora of Alternate Rates and Corresponding 33706 Weights WPS480 An Evaluation of Neutral Trade Policy Jaime de Melo August 1990 R. Sugui Incentives Under Increasing Returns David Roland-Hoist 37951 to Scale WPS481 The Effects of Trade Reforms on James Tybout August 1990 R. Sugui Scale and Technical Efficiency: Jaime de Melo 37951 New Evidence from Chile Vittorio Corbo WPS482 Membership in the CFA Zone: Shantayanan Devarajan August 1990 R. Sugui Odyssean Journey or Trojan Horse? Jaime de Melo 37951 PRE Working Paper Series Contact AuthoArh for paper WPS483 An Evaluation of the Main Elements Refik Erzan August 1990 G. llogon in the Leading Proposals to Phase Paula Holmes 33732 Out the Mufti-Fibre Arrangement WPS484 Stock Markets, Growth, and Policy Ross Levine August 1990 R. Levine 39175 WPS485 Do Labor Market Distortions Cause Ram6n Lopez August 1990 R. Luz Overvaluation and Rigidity of the Luis Riveros 34303 Real Exchange Rate? WPS486 A RMSM-X Model for Turkey Luc Everaert August 1990 S. Aggarwal Fernando Garcia-Pinto 39176 Jaume Ventura WPS487 Industrial Organization Implications Timothy Condon August 1990 R. Sugui of QR Trade Regimes: Evidence Jaime de Melo 37951 and Welfare Costs WPS488 Prepaid Financing of Primary Health Per Eklund August 1990 K. Brown Care in Guinea-Bissau: An Knut Stavem 35073 Assessment of 18 Village Health Posts WPS489 Health Insurance in Zaire Donald S. Shepard August 1990 K. Brown Taryn Vian 35073 Eckhard F. Kleinau