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