Table B.4 shows the cash flow of<sup>Bokoro Hospital from 1986 through the first six months of</sup> 1989. Revenues from operations together<sup>with subsidies cover hospital expenses every year.</sup> While in 1986 almost 99% of operating<sup>expenses came from operating revenues, this share</sup> dropped to 56% the following year.<sup>In 1988 and 1989, respectively, 34% and 38% of operating</sup> expenses are covered from subsidies.<sup>The Catholic mission, the Belgian Cooperation, SANRU,</sup> FONAMES, and the government of<sup>Zaire contributes salaries for some of the personnel.</sup> The share of expenses for drugs and<sup>medical supplies has doubled over the past four years and</sup> is approaching 50% of the hospital's<sup>recurrent costs.</sup> It was not possible to distinguish<sup>between revenues from insurance funds and direct patient</sup> charges. The hospital budget is shown<sup>to cnable a calculation of necessary revenues from a</sup> hypothetical insurance for hospital<sup>care. Given the present subsidies and the present level of</sup> services the hospital would need a<sup>minimum of 40,000 subscribers. Including anticipated</sup> administrative costs for the insurance<sup>plan and an inflation rate of 60%, a premium of 200</sup> Z per person would seem necessary.

# 4. Utilization and Access

Rates of utilization of ambulatory care<sup>services at the Bokoro Health Center for the first six</sup> months in 1989 are shown in Table B.5.<sup>D.fferences in utilization between subscribers and the</sup> uninsured are striking. Based on the<sup>six months average, subscribers consult five times as</sup> often as non-subscribers with a new disease.<sup>Rates of treatment with antibiotics, antibiotic</sup> prescriptions, and injections show a similar<sup>pattern. Subscribers use two to nine times as many</sup> services. Their higher utilization rate<sup>is not necessarily due to insurance, however. Every plan</sup> subscriber is employed and all medical<sup>expenses for the family are covered anyway.</sup> In the household survey, mentioned earlier,<sup>respondents were asked about their preferences</sup> regarding health insurance. A single<sup>annual payment of 100 Z to 200 Z per family member</sup> seemed affordable. The preferred times<sup>to pay were January, July, and August. The survey</sup> of members showed that they were interested<sup>in broader coverage that would include hospital</sup> care as well as ambulatory care (see Table<sup>B.6). While hospitalized patients naturally preferred</sup> hospital care, a majority of healthy villagers<sup>preferred ambulatory care.</sup> A major handicap to wider enrollment<sup>is probably the lack of an incentive for the health</sup> personnel to attract new subscribers.<sup>The staff of health centers are evaluated and rewarded</sup> with an incentive payment for an overall<sup>high utilization rate, correct operational procedures</sup> and having more revenues than expenses.<sup>No incentive is provided for new plan subscribers.</sup> These would merely add to the work load<sup>but not necessarily increase the profit.</sup> Health zone administrators complained<sup>that clinical personnel did not believe in the value</sup> of the insurance scheme. Thus, their publicity<sup>and educational efforts were minimal or even</sup> negative. No clear policy had been formulated<sup>regarding the best enrollment period.</sup> The authors felt that if the premium<sup>were lower, substantially more subscribers would enroll</sup> and would dilute the present high risk<sup>membership with more low risk subscribers. The health</sup> committee members and health center<sup>staff with whom they spoke, however, could not follow</sup> t;.is argument.

The study team felt that respected community<sup>institutions could assist in publicizing the idea</sup> of a prepayment plan. In Bokoro, the<sup>Programme des Actions Complementaires (PAC) might</sup> serve this role. It was created to promote<sup>social services, agricultural and fishing activities</sup> and 4% associated with the BCZS. Also,<sup>two religious missions (Catholic and Baptist) have</sup> contributed greatly to the development<sup>of the Bokoro area over the past 70 years. They enjoy</sup> great confidence of the population<sup>which could be an important factor for a successful</sup> 33