# **Table A.9** Survey of HospitaLized Patients in Bwamanda

|. ..............................................<br>Characteristic|Insure<br>(N229)<br>Mean<br>|...........<br>d<br><br> <br>**STO**<br>|.......<br>Uninsur<br>(M221)<br>**Mean**<br>|..............<br>...........................<br>ed<br> <br>Stat.<br>STD Sig.<br>..............|
|---|---|---|---|---|
|...........................................<br>|..........<br>|......................<br> <br>|.............................<br> <br>||
|Age in years|20|<br>**19**|<br>22|**20**|
|**Payment**for current<br>hospitalizatio<br>in**Zaire**|n<br>1568|1700|<br>4083|4070<br>-|
|Number<br>of episodes<br>of**serious**<br>**ilLnes**<br>In househoidduring 1988**and**1989|**s 2.4**|**2.9**|<br>**1.6**|**1.2**|
|Nutber<br>of hospitalization<br>episodes<br>in.househotd during 1988 and 1989|2.6|4.4|1.7|1.2|
|Nuiber of times the patient was|||||
|hospitalized from 1985 thru 1989|2.8|2.7|1.3|1.8<br>-|
|Number<br>of persons in househoLd:|||||
|Children|5.5|6.7|5.6|3.1|
|Younger<br>aduLts<br>|**3.8**<br>|3.5<br>|2.7<br>|1.2<br>|
|Elders<br>|0.7<br>|1.1<br>|0.6<br>|0.7<br>|
|TOTAL|10.0|8.4|8.9|3.3|

For employed persons, both the hospital and the patient have every incentive to hospitalize. Care is free to the employee, and the hospital is paid two to three times the fee of a selfpaying patient. The problem of higher hospital use by insured patients has not had a serious effect on the financial solvency of the insurance plan, since the plan covers such a large percentage of the population (60%). With lower enrollment, such a problem could bankrupt an insurance system. The fact that insured patients use only a third to a half as much hospital care as employed persons suggests that the 20% copayment may have limited moral hazard.

Principles of medical geography suggest that people will consume more health services the nearer they live to the site of care. By examining the pattern, one can see whether the data on utilization rates are plausible. Further, by examining utilization for both distance and insurance status, simultaneous possible confounding between these variables can be eliminated. The figure shows that insured patients used more services, regardless of distance. A similar pattern held for internal medicine admissions (one third of all admissions), separately.

Overall hospital admission rates for all services (excluding obstetrics) were also examined by distance for 1989. Figure A.2 shows the regression of admissions for all payment categories and admissions with insurance coverage on distance from the hospital. The 21 observations are villages covered by Bwamanda Hospital.

There was no evidence of any meaningful difference in delay between insured and uninsured patients. A patient going to Bwamanda Hospital knows that he must pay on or near admission. As an uninsured patient faces higher fees, it may take him longer to assemble the necessary cash. Using data from Kombo, Bombisa, and Dondeme Health Centers, the authors found minimal delay among both insured and uninsured patients in both groups.

In previous work, Moens had examined whether patients actually followed up on referrals to the hospital. He found that rates were high and comparable for both insured and uninsured patients.

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