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