the system that could be used to assess its financial<sup>health. In CASOP, the financial system</sup> was so incomplete that no financial statement<sup>could be constructed for either the polyclinic</sup> or the insurance system. In Bokoro and St.<sup>Alphonse, financial statements for the health</sup> centers could be constructed, but premium income<sup>and expenses of insured patients could not</sup> be separated from the centers' other financial<sup>transactions. Bwamanda constructed an annual</sup> financial statement for the insurance plan<sup>at the end of each year, but it contained so many</sup> year end journal entries that no meaningful<sup>analysis could be performed mid-year.</sup> Better financial accounts would aid the insurance<sup>systems in setting premiums and controlling</sup> costs, as well as providing better data to<sup>guide future policies.</sup>

# 7. A Financial Guarantor Can Help Build<sup>Confidence in Launching an Insurance System</sup>

When a new insurance system is established,<sup>many factors could precipitate insolvency.</sup> Accumulated health problems could lead<sup>to an initial burst of demand. Inadequate data or</sup> limited information could lead to underestimation<sup>of utilization or prices. An insurance plan</sup> may incur fixed expenses despite low enrollment.<sup>The public will be more likely to enroll in</sup> an insurance system if they are protected against<sup>these outcomes. Many organizations could</sup> serve as a financial guarantor. In Bwamanda,<sup>the CDI served this role. (Fortunately, it was</sup> never required to make good on its guarantee.) In the future in Zaire, this study encourages existing<sup>organizations to serve as guarantor. The</sup> Government of Zaire, with support of PASS, the<sup>SANRU program, Sante Pour Tous, UNICEF,</sup> or a PVO might serve this role. The financial<sup>guarantee need only be given for one year at</sup> a time. If there are losses, the premiums or services<sup>can be revised or, if necessary, the system</sup> can be abandoned to prevent further losses.

# C. **RESOURCE MOBILIZATION**

# **1.** Access and Resource Mobilization Motivated Health<sup>Insurance Schemes</sup>

Health insurance systems were started primarily<sup>to meet two objectives concurrently:</sup> mobilizing resources and increasing access<sup>to services. In the health zones of Bwamanda and</sup> Bokoro, the hospitals had chronic or mounting<sup>deficits. They felt that substantial increases</sup> in user fees would price their services beyond<sup>the ability of the population to pay. With health</sup> insurance, ill persons would be more likely to<sup>seek care. As evidence of the goal of increasing</sup> access to health services, the insurance systems<sup>were promoted by developmental organizations</sup> such as the Center for Integrated Development<sup>in Bwamanda, the Development Committee of</sup> St. Alphonse Parish in Kinshasa, and the social<sup>welfare structure of CASOP. In Bwamanda,</sup> where the most detailed financial statements<sup>were available, the share of the hospital's</sup> operating costs recovered rose from 48% in<sup>1985 to 79% in 1988.</sup>

# D. **UTILIZATION AND ACCESS**

# **1. Evidence** of Adverse Selection and Moral Hazard<sup>was Found, But Plans Minimized</sup> Their Impact

In every plan for which utilization of insured<sup>and uninsured persons could be compared,</sup> insured persons were found to use more services.<sup>In Bwamanda, insured persons were 6.7</sup> times as likely as uninsured to be hospitalized.<sup>At Bekoro health center, plan subscribers had</sup> 5.0 times as many new ambulatory episode as<sup>non-subscribers. In the Kinshasa surveys, insured</sup> respondents reported more previous visits (2.0)<sup>for their current illness episode than uninsured</sup> (1.6). Similarly, utilization data from CASOP<sup>showed more visits per episode among</sup> individuals insured (2.5) than among those uninsured<sup>(2.0).</sup> While comparisons among the diverse insurance<sup>plans require caution, this evidence suggests</sup> 59