operating costs (excluding depreciation) incurred by beneficiaries. Capital costs were considered the responsibility of the government and donors.

To calculate the each new year's premium, the medical staff (primarily the Director of the CDI's medical service) first build the budget for the new year, based on historical costs corrected for historical inflation, and incorporating estimates about the next year's inflation rate, further devaluation of the zaire, and other budget parameters. The staff then divide the estimated operating costs by the total population to obtain the per capita cost of hospitalization for the next year. Using various assumptions about the percentage of the population likely to enroll in the plan, and the expected revenue from uninsured patients (who would pay full charges), the zone calculates projected cost recovery for the hospital as a whole. The premium for the health insurance plan is then set through discussions involving the whole staff and incorporating social goals as well as cost recovery objectives. For example, the projected premium is compared with the price of two kilograms of soy beans (a commonly produced crop), as a measure of affordability. The medical staff tries to assure that the premium is sufficiently large to cover the claims of the beneficiaries, with some margin of error.

Financial records were not kept accurately the first year, although the plan seemed to cover costs. Using Bitran's data (4), the cost per hospitalization in 1985 vsas 3:6 Z. (1,803,844 Z total hospital operating costs excluding depreciation divided by 5,711 hospitalizations.) The probability of being hospitalized in 1985 was 5% (5,711 hospitalizations divided by 114,410 inhabitants). Therefore, the expected cost of hospitalization per inhabitanit was 15.8 Z (5% x 316). The premium was set 21% higher than the expected cost, presumably to cover administrative costs, and possible adverse selection.

The premium is collected once a year, at harvest time. There are two harvest periods in the Bwamanda zone; one in July-August, the other in January-February. When communities were asked when they would prefer to make the premium payment, they overwhelmingly preferred the months following the second harvest period (March to April), because they needed cash in August to pay for school expenses (14).

Collection of the premium takes place during a six-to-eight week period in February through April. Prior to this, several preparatory meetings are held with health center staff to orient them to any new changes in plan premiums and administrative procedures, and to present them with the time table and control procedures for the registration period.

Residents enroll in the insurance plan at their health center. When the payment is made, a stamp printed with the name of the health zone and the price is affixed on the individual's medical identity card. The medical card includes the individual's name, village, and enrollment number, and allows space for critical medical events to be registered (vaccinations, prenatal consultations, hospitalizations, etc.). A second stamp, with different color print, is placed on the family health card, which stays at the health center. The health center nurse signs his/her initials over the stamp on the medical card, taking care that the signature also touches the card, to avoid cases of fraud where unsold stamps are stolen and affixed to cards, or stamps are moved from one person's card to another's.

The health center nurse also registers information about each enrollee in special notebooks, which **are** organized by village. These notebooks are then used for control purposes at the hospital level to control that the bearer of an insurance card is really the person named who registered.

5 Annex IV provides examples of many of the documents described below and in the subsequent section on identification of the uninsured.

18