Intensive care Surgery Obstetrics (where mother has attended prenatal convsultations) Gynecology The insurance plan also covers the cost of treatment of chronic illness at the health center and health post.

Each clinical service has one to four sub-departments, bringing the total number of covered hospital clinical services to 14.

Two add-tional clinical services have been designated by the hospital but are not covered by the insurance plan. These are: 1) private doctor visit or physical examination, and 2) deliveries of mothers not enrolled in prenatal consultations. Including these two services, the hospitil has a total of 16 clinical services. The Bwamanda hospital has employed a system of flat rate charges for episodes of illness or hospitalization for 10 years.

The charge varies by payor category. A list of hospital services, along with pricing information according to payor category, is attached in Annex II. Each price covers all resources required for treating the inpatient episode, including nursing, doctor visits, laboratory and X-rays, pharmacy, operating room time, housekeeping and supervised day treatment, etc. The standard price given in column A, applies to an uninsured patient included in the zone census. A non-member (column B) generally pays 20% of the standard price. People from outside the Zone (i.e. not in the census) generally pay twice the standard price; employed persons whose employer pays directly pay 250% of the standard price.

The population eligible to join the insurance plan includes all residents of the health zone of Bwamanda. Villages are often very large (1,000 to 2,000 inhabitants); the population density is 54 persons per square kilometer. Health centers usually serve between 4,000 to 8,000 people, and 99% of the population lives within 7 kilometers of a health center (14).

According to the health zone census, about 17% of the population are children under five. In a 1987 survey of 518 households, about half the households reported annual revenue of less than 7,500 Zaires _($58).'_ The same survey showed an average household contained five children and 7 to 8 members overall.

About 90% of the population of the health zone are farmers. The major crops are coffee, soy beans, corn, cotton, peanuts and cassava. In some parts of the zone, fishing is an important activity. About 4.6% of the zone's population are salaried employees and their families. These employees work for private or parastatal companies. The largest of these employers is the CDI itself, with 617 employees (a total of 3,480 covered beneficiaries). An unknown number of residents earn salaries working for small shops or other small businesses.

Table A.l shows the evolution of membership in the insurance plan, from 1986 to 1989.

To better characterize insured and uninsured patients, the study team interviewed 50 of the 196 hospitalized patients in a systematic survey hospitalized on November 2 or November 3, 1989. The questionnaire (in Lingala) is in Annex V. Table A.2 compares the insured and uninsured inpatients who used the hospital. Insured patients were more like'v to be female and were less educated. Otherwise, there were no noticeable differences. As only one respondent was employed, it was not possible to separate ordinary uninsured and employed 3 The Zaire, the unit of currency of Zaire, has been subject to rapid inflation. As of the time of this study (mid-October, 1989) one US dollar was worth 430 Z officially and about 470 Z on the parallel market.

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