# **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<sup>to 450</sup> **Z** for a member.

By contrast, in rural Bokoro the annual premium per person (not per family) was 1200 _Z_ 55