## A. CASE STUDY OF BWAMANDA

The health zone of Bwamanda, located in the Equateur Region of Zaire, operates under the medical services of the Center for Integrated Development (CDI) of Bwamanda. The CDI was started in 1969 with assistance from Belgian missionaries, to support economic and social development, including agriculture, health, nutrition, and infrastructure. The health zone's 1989 population of 134,682 is served by a 156-bed reference hospital, 20 comprehensive health centers, and two smaller health posts.

The following section gives a brief introduction to the insurance plan operating in Bwamanda, and its context. The section describes the terms of the insurance package, charactcristics of the population served, and the organization and management of the plan. Subsequent sections describe the financial condition of the insurance plan and the hospital, and analyze issues of efficiency, cquity, and demand for services.

This discussion draws on previous work by health zone staff and other research teams, reported in several documcnts; Moens (1988), Bitran (1986), Vian and Nsembani (1986), and Bwamanda Health Zone (1985-1988) (Annual Reports of the Health Zone).

# 1. Terms of the Insurance Plan

Several concerns led decision makers to consider the development of an insurance plan as a health financing option for the zone of Bwamanda. Most important, the zone's medical staff wished to increase economic access to health care and to improve the hospital's financial situation. Regarding access, fluctuations in income due to seasonality of crops meant that it was not easy for individuals to pay the full cost of a hospitalization. Medical staff were also concerned that individuals who had becn referred to the hospital were delaying several days to come, in order to gather enough money to pay for the care (14).

Regarding the financial situation of the hospital, a study in 1986 showed that the hospital had recovered less than half of its operating expenses through user fees in 1985. Compared to the eight other hospitals analyzed by Bitran et al, Bwamanda performed the worst in share of costs recovered from patients (4).

The process of designing the insurance plan included considerable participation from both medical staff (including health center nurses) and the communities. First , hospital staff discussed the acceptability of the plan with health center nurses. Through these workshops discussions, the basic parameters of the plan were set, for example, a small so-payment, no deductible, and annual collection rather than semi-annual premiums. The idea of covering ambulatory care through the insurance plan was also discussed during these preliminary workshops. Overwhelmingly, the nurses rejected this idea because they believed it would result in overutilization of medical services (14).

At the level of the community, meetings were held to explain the basic elements of the proposed insurance plan, and to ask community members for their preferences regarding premium and co-payment levels. Presented with two options, the communities expressed preference for a higher premium and lower co-payment (14). Health zone staff regularly solicit community opinion regarding the health insurance plan, through the CDI's community development committees.

The Bwamanda insurance plan covers hospitalizations (including deliveries), dental extractions, and ambulatory surgery (circumcisions) at the Bwamanda Hospital. Covered care span six clinical services: Pediatrics Internal medicine 12