metadata: authors: 0: author: Vogel,Ronald J.
count: Africa
docna: 0: docna: Health insurance in sub-Saharan Africa : a
            survey and analysis
docty: Policy Research Working Paper
subtopic: Health Care Services Industry,Labor Markets,Health Economics & Finance,Health Service Management and Delivery,Health Insurance,Rural Labor Markets
teratopic: Health, Nutrition and Population
abstracts: cdata!: Health insurance is one in a portfolio
            of options that are available to augment government
            budgetary resources for health-care spending. Yet, little
            comparative information is available on the kinds of health
            insurance that are presently extant in sub - Saharan Africa.
            The purpose of this paper is to fill that gap in knowledge
            and to define "health insurance". The paper also
            discusses: (a) the prevalence of health insurance; (b) the
            contribution of health insurance to health finance; and (c)
            the characteristics of the health insurance. These schemes
            are analyzed with respect to insurance criteria developed in
            the research literature on health insurance. The paper
            concludes by summarizing what has been learned and the
            conclusions that can be drawn.
repnme: repnme: Health insurance in sub-Saharan Africa : a
            survey and analysis
display_title: Health insurance in sub-Saharan
            Africa : a survey and analysis
listing_relative_url: /research/1990/08/700208/health-insurance-sub-saharan-africa-survey-analysis
topicv3: Private Health Insurance m1326150 1292,Labor Markets m1326488 855,Health Insurance m1327759 1287,Health m1504661 3480,Hospital Care m1504670 3597
publishtoextweb_dt: 2010-07-01T00:00:00Z
historic_topic: Health, Nutrition and Population
origu: Policy, Research & Ect Affairs
no_of_pages: 45
author_keys: 0: author_key: 869326
model_extractions: **Policy, Research, and ExternalPffairs**

**Population, Health, and Nutrition**

WPS 476

- This paper a product of the Population, Health, and Nutrition Division, Africa Technical Department -was written as part of a Regional Study on Health Financing, with financial support from NORAD and SIDA. It was presented at a seminar in April 1990 and will eventually be part of a World Bank technical paper. Copies are available free from the World Bank, 1818 H Street NW, Washington DC 20433. Please contact Karol Brown, room J9-112, extension 35073 (40 pages, including tables).

Based on a survey and analysis of health insurance in 23 countries in Sub-Saharan Africa, Vogel reached certain conclusions: Most Ministry of Health (MOH) budget expenses in these countries (with the possible exception of Tanzania and Ethiopia) are skewed to a small, well-defined population. The well-todo pay for the "best" health zare in the private sector, out of their own pockets or through insurance policies (usually from foreign sources).

Most poor people rely on the MOH budget as an implicit or informal formn of national health insurance or on traditional healers for whose care - they mnust pay out of pocket paying more for traditional healers and drugs than they might copay on health insurance. MOH spending is low in the geographical aieas where the poor live and for the kinds of health care the poor use, so the poor benefit little from these informal national health insurance systems.

The small middle class benefits most from health insurance in Sub-Saharan Africa. In the private sector, employers provide health care either directly or on contract - which is effectively health insurance. As government employees, they get preferential treatment under formal and informal health insurance, even national health insurance. The countries in Sub-Saharan Africa have not given the poor more, or more equitable, access to formal health insurance.

And the forms of health insurance adopted in Sub-Saharan Africa do not encourage efficiency.

Zimbabwe, for example, where private insurance has grown rapidly since independence, has used the U.S. Blue Crosc/Blue Shield model that existed in the United States in the 1960s and 1970s - in which the tax system heavily subsidized health insurance, all kinds of medical risk were covered (even for frivolous purposes), and neither the providers or consumers of health care were encouraged to restrain costs - so that health costs increased rapidly. One way or another, all the health insurance arrangements Vogel studied have the same perverse incentive effects that those open-ended, cost-based retrospective Blue Cross insurance payments had on health care providers.

Reform of these arrangements will be politically difficult. In countries with an implicit national health coverage, more equity for the poor requires that more of the MOH budget be directed their way. One way to do this would be to eliminate any favorable treatment government employees receive in the health care system. The availability of more private health insurance would similarly free more MOH resources. Govermments must examine the regulatory and incentive atmosphere to be sure they are not inhibiting the development of private health insuirance.

But they must also be careful that the private health insurance that does develop fosters more efficient health care. Prepaid capitated health insurance will encourage efficiency by health providers; deductibles and coinsurance have similar effects on health consumers.

Thc PRE Working Paper Series disseminates the findings of work under w?v in the Bank's Policy, Rcsearch, and Extemal AffairsComplex. An objective of the scries is to get these fuidings out quickly, even ifpresentations are less than fully polished. The findings, interpretations, and conclusions in these papers do not necessarily represt't official Bank policy.

Produced by the PRE Dissemination Center
# Health Insurance in Sub-Saharan Africa: A Survey and Analysis

by Ronald J. Vogel

# Table of Contents

|I.|Introduction|1|
|---|---|---|
|II.|What Constitutes Health Insurance?|2|
|III.|The Prevalence of Health Insurance|5|
|IV.|The Contributi-.of Insurance to Health Finance|7|
|V.|The Characteristics of the Health Insurance|10|
|VI.|Analysis of the Major Issues in Health Insurance and<br>Lessons to be Learned|14|
|VII.|Summary and Conclusions|21|
|Refer|ences|25|
|Table|s|27|

This study was conducted as part of the Africa Regional Studies Program on Health Financing in Sub-Saharan Africa, managed by the Africa Technical Department, Population, Health, and Nutrition Division, with financial support from NORAD and SIDA.
1

# I. Introduction

In recent years, there has been a slow-down in economic activity in many Sub-Saharan African countries, brought about by severe droughts in the region, the worldw4.-Ae recession in the early and mid-1980s, and unfavorable changes in the te-:s of trade for their agricultural and mining products. Falling per ceH'ca real incomes, a worsening external debt situation, and widening budget deficits have been the consequence. As a result of these economic circumstances, Ministry of Health (MOH) budgets have tended to decrease as a percent of the total government budget and even to decline on a real per capita basis.

Within this context, Ministries of Health have increasingly looked for ways of mobilizing additional resources in order to meet the health needs of the population. Health insurance is one in a portfolio of options that are available to augment government budgetary resources for health-care spending. Yet, little comparative information is availablt on the kinds of health insurance that are presently extant in Sub-Saharan Africa. The purpose of this paper is to fill that gap in knowledge. The next section of this paper attempts to define "health insurance". Then, the three following sections discuss, respectively: (a) the prevalence of health insurance, (b) the contribution of health insurance to health finance, and (c) the characteristics of the health insurance. A following section analyzes these schemes with respect to insurance criteria developed in the research literature on health insurance. The final section of the paper summarizes what has been learned and the conclusions that can be drawn.
2

# II. What Constitutes h,.alth Insurance?

Health insurance might be defined in various ways. For example, at some level of abstraction, a government health care system, financed through general tax revenues and provided without charge to the population could be considered to be a form of national health insurance, albeit an implicit or informal one. Likewise, throughout Sub-Saharan Africa, many firms provide free health care to their employees and to their families, either in the form of company-run clinics, or through contracts with private physicians and clinics. In some countries (e.g., in Zaire), this kind of coverage is mandated by government. At another level of abstraction, this too could be considered to be 'health insurance", because, in effect, the employer is required to maintain a pool of funds for health care (analogous to a sinking fund for the depreciation of physical capital), and, depending upon elasticities of the demand for and supply of labor, much of the "premium' may be shifted onto labor. In other countries (L.S., in Zimbabwe), employers voluntarily provide company clinics or pay for health care for their employees and their families through contracts. Human capital theory would allow this practice to be considered to be providing health insurance, particularly for skilled and not-easily-replaced employees; in effect, the employer is selfinsuring against the loss of skilled labor, particularly where the skilled labor is highly specialized, and hence, highly scarce.

Table 1 provides a typology for thinking about the nature of the conceptual problem in defining "health insurance". Health-care risk-spreading mechanisms (health insurance) can either be mandated by government, or government and the private sector can offer risk-spreading plans that are voluntary. Because one of the major objectives of many government health
3 insurance arrangements is usually to pool risk (or to redistribute the paying for the pooling of risk), participation in government arrangements is almost always compulsory. As shown in Table 1, government implicit and explicit health 'nsurance arrangements in Sub-Saharan Africa can be broadly characterized as ranging from (A) free health care provided and financed for all citizens (e.g., Tanzania), or through (B) health care provided bgovernment and financed through the general tax fund and through cost recovery (.., Ghana), (C) compulsory Social Security for the entire formal labor market (L.L, Senegal), (D) a special health insurance fund for government employees (e.L,, Sudan), (E) a discount at health care facilities for government employees (e.g., Ethiopia', (F) other public "insurance", such as government employees being entitled zo private medical care as a fringe benefit (L.g., Kenya), and finally (G) mandated employer coverage of health care for employees (s..g., Zaire). Likewise, in the private sector, one observes (A) private insurance policies bought from insurance companies (e.g., Zimbabwe), (B) small local voluntary risk pools (e.g., Rwanda), and (C) employers voluntarily providing medical care directly (e.g., Zambia) or providing medical care on contract with private health-care providers (e,&., Nigeria). Each one of these arrangements spreads risk in varying degrees, and the incidence of the payment for the spreading of the risk also varies, depending upon elasticities of supply and demand for labor, and the progressivity of the tax system used to finance the governmental arrangements. Having considered these conceptual problems, some operational definitions had to be made. Therefore, for purposes of this paper, "health insurance" is defined as a formal pool of funds, held by a third party, (or by the provider, in the case of a Health Maintenance Organization, which relies on prepayment
4 by its insurees), that pays for the health-care costs of the membership of the pool. This third party can be a governmental social security or other public insurance fund-pool, or any private fund-pool. Given this conservative definition of formal health insurance, employer-proviued health care is not considered 'health insurance"1. Nonetheless, it must also be pointed out that, to the extent that these employer arrangements exist, they do free-up resources for MOH expenditures for the rest of the population.

By way of summary to this section, and as a general introduction to the next three sections, we briefly describe Tables 2, 3, and 4. These three Tables summarize the information on the health insurance schemes that exist in the Sub-Saharan countries that have been recently researched, and their contents will be more fully describe" and analyzed in each of the following three sections of the paper. The sources for the dqta in all three Tables are listed under the last column of Table 4. Table 2 is entitled, "Coverage of Health Insurance in Sub-Saharan Africa". The countries are listed in alphabetical order. The main purpose of Table 2 is to ascertain what percent of the population is covered by health insurance; health insurance is divided into the three mutually exclusive categories of "Social Security", "Other Public Irsurance", and "Private Insurance." The final column in Table 2 shows the percent of the population that is insured in each country.

Table 3 shows the contribution of health insurance to health finance in each country. The column headings show six sources of health-care financing: in the public sector, (1) the MOH budget, (2) the Social Security Budget, (3) 1However, some entries in Tables 2, 3 and 4 do try to give some estimate of the extent to which this arrangement exists, in countries where data are available.
5 Other PublVc Budget, and in the private secotr, (4) Out-of-Pocket, (5) Private Insurance, and (6) Other Private. The last three columns of Table 3 show, respectively, (1) the share of out-of-pocket in total national health expenditures, (2) the share of private insurance, and (3) the share of public insurance.

Table 4 shows the characteristics of health insurance in Sub-Saharan Africa, according to: (1) groups covered, (2) type of management, (3) number and percent of the total population enrolled, (4) services covered (inpatient, outpatient, preventive, and drugs), (5) unit of enrollment, (6) uniform premium, (7) copayment and/or deductible and (8) the total budget of the insuring entity. The last column in Table 4 contains clarifying comments on the other column entries in Table 4, and the sources for the data in Tables 2, 3, and 4.

III. The Prevalence of Health Insurance Table 2 summarizes the extent of explicit, or formal, health insurance coverage relative to population size in the 23 countries studied. As might be expected, there is a wide variation in the percentage of the population covered. Many countries simply have no formal health insurance arrangements. For the 7 countries with formal health insurance (as defined above), the percentage of the total population insured ranges from a high of 11.4 percent in Kenya to .001 percent in Ethiopia. Thus, an important source of additional finance is being neglected and the relatively poor are bearing a larger share of the risk than the rich. Table 2 shows that government employees are always given preferential treatment within public forms of health insurance. In Ethiopia, for example, government employees receive a 50 percent discount at
6 government facilities, whereas the rest of the population, except for the very poor, does not receive the discount. As another example of this kind of preferential treatment, civil service employees in Kenya are entitled to private medical care as a fringe benefit; this fringe benefit is paid from funds in the MOH budget, and cost 2.2 percent of the total MOH budget in 1986. G-vernment employees are exempt from hospital admission charges in Guinea. In Mali, each ministry is expected to pay for 80 percent of its employees' health-care costs. Also, there is wide variation in the use of the Social Security system as a vehicle for health insurance.

The prevalence of private formal health insurance in Sub-Saharan Africa is extremely small, as evidenced by the low percentage of the population covered. Private insurance has a foothold in only 6 courtries: Cote d'Ivoire, Ethiopia, Kenya, Nigeria, Swaziland and Zimbabwe. Even in Zimbabwe, where private insurance is comparatively well-developed, it only covers 4.6 percent of the total population. In Kenya, about 60,000 persons are covered by private health insurance plans, although the private insurance market for hospital care, at least, seems to have been preempted by the National Hospital Insurance Fund (NHIF), established in 1967, which is similar to Social Security in other Sub-Saharan countries, and which covers 2.1 million persons in Kenya<sup>2</sup> . Most private health insurance schemes seem to cover the upperincome classes in the countries for which such information is available. As was alluded earlier in this section and can be seen in the various footnotes 2In Zimbabwe, the National Association of Medical Aid Societies (NAMAS), which is the national association of private insurers, estimates that eventually it will be able to reach about 10 percent of the population of Zimbabwe, i.e., only about 10 percent of the population can afford to pay for private health insurance. The 2.1 million persons covered by the compulsory NHIF in Kenya is approximately 10 perce-t of the population of Kenya.
7 for t&ie countries in Tables 2, 3 and 4, many private companies in the countries directly provide free health care to their employees or ccntract for it. In this respect, Lesotho is a curious case, because many of its workers obtain employer health coverage in South Africa, ...to and out of which they migrate for work; apparently their wives and children who remain in Lesotho depend upon the government of Lesotho for health care.

Finally, in studying the contents of Table 2, particularly for a country like Kenya, one wonders how many resources could be freed for the use of the poor, if expanded insurance coverage were provided to any more groups. In Kenya, at least, there already appears to be fairly widespread insurance coverage of the middle and upper classes, such that it would seem to be politically possible to devote more MOH resources to the poor. However, the Kenyan health-care system remains urban and hospital intensive, even though the large majority of the population lives in rural areas.

IV. The Contribution of Insurance to Health Finance Table 3 shows the contribution of health insurance to health-care finance. Total recurrent expenditures are divided between the public and private sector, and between public arwS private insurance sources; out-ofpocket expenditures are also included. However, the definition of out-ofpocket expenditures does pose some conceptual difficulties, depending upon whether the patient goes to a modern or traditional healer. For example, some governments practice cost recovery. If a person goes to a government healthcare facility, he/she may pay for 20 percent of the cost of the care. This is clearly an out-of-pocket payment. If the same person goes to a traditional healer, and the cost of the treatment there is only one-fifth that in a
8 government facility and the person pays 100 percent of this cost, he/she has paid the same total amount as at the government facility. The basic problem here is directly related to the definition of total health expenditures in a country. The truth of the matter is that estimates or expenditures for traditional care vary widely from country to country 'Vogel 1989a) an" from 3 analyst to analyst. These traditional health expenditure estimates make up part of the "total" for each country in Vogel (1989a), but they appear unreliable. To the extent that they ."r.not be used in the base for healthinsurance ratio comparisons, the percent of health expenditures that is insured becomes distorted. For the share (ratio) comparisons in the last three columns of Table 3, traditional health care expenditures are excluded from both the category "out-of-pocket" and from the base, simply because they appear to be too variable and unreliable (Brunet-Jailly, 1988).

Estimates on tie percentage share of out-of-pocket expenditures, including user fees and private expenditures, in the total range from 7.3 and 7.4 percent in Malawi and Mozambique, respectively, to i0 1 and 72.1 percent in Uganda and Mali<sup>4</sup> . Part of this variability may be due to imprecision in the measurement of the total-expenditure base of the ratio. Although every effort was made to include only those foreign aid expenditures in the total that were clearly for recurrent expenditures, some investment expenditures may have slipped into the estimates in the reportt for each country that were used as sources.

3As an example, see the discussion in Brunet-Jailly (1988).

'These estimates come from the source documents listed in the last column in Table 4.
9 Ono pattern that seems to emerge with respect to out-of-pocket costs is that in countries where there are large mining and enterprise interests, such as in Swaziland, Zaire, Zambia and Zimbabwe, the percentages of out-of-pocket expenditures (at least for fo=al care) seem to be lower than in countries where such activity does tlot exist. What makes all of these estimates difficult though is the paucity and unreliability of the existing data on expenditures upon traditional care. For example, the out-of-pocket share for Burkina Faso, an extremely poor country, is 25.4 percent and it is 29.9 percent in Guinea, which seem to be low relative to the 56.9 percent in the Cote d'Ivoire. However, these percentages may simply reflect the fact that the Cote d'Ivoire has been a relatively large iLporter of pharmaceuticals (see Vogel 1989a) for which people willingly pay cash at the many private pharmacios located around the country, but principally in the more affluent ci_ies. Because of a lower per capita economic- base and lower rate of economic growth, people in Burkina Faso and in Guinea do not have the pharmaceuticals available for purchase, and therefore turn to tradittonal healers; these people may be spending as high a share out-of-pocket, or even higher, than the people in the Cote d'Ivoire, but this will not be reflected in the kind of data in Table 3.

The share of private insurance in the total ranges from zero _ 16 of the 23 countries to 15.0 and 16.5 percent in Senegal and Zimbabwe. The estimate on private insurance expenditures in Zimbabwe is fairly firm, because the National Association of Medical Aid Societies (NAMAS, the approximate equivalent of the Blue Cross/Blue Shield Association in the U.S.) keeps good statistics. The large share of private insurance for Senegal (15 percent) may simply be an artifact of the large expatriate community (mostly French) living
10 5 in Senegal. The expatr'dtes are usually insured by sources outside of Sentegal, such as the French Prevoyance Sociale, that pay expatriate health care bills in Senegal. As a case in point, the private Hopital Principal in Dakar is totally supported by insurance payments and out-of-pocket expenditures by its clientele which is largely expatriate. The annual budget of the Hopital Principal is about one-third the size of the Senegalese MOH budget.

The interpretation of the share of formal public insurance in the total ii also subject to some ambiguity. For example, in Burundi (16.4 percent), public insurance is dominated by the Mutuelle de la Fonction Publique which is for civil servants. On the other hand, Table 3 shows no public health insurance in Nigeria, yet some 30 million (out of a total population of some 103 million) government employees and their families receive free health care from government facilities. Likewise, in Zambia public insurance finances 24.1 percent of recurrent health expenditure. This figure results from the fact that the parastatal, Zambiar. Consolidated Copper Mines (ZCCM) has established a formal health insurance pool for the employees of the association.

# V. The Characteristics of the Health Insurance

Table 4 presents the characteristics of the health insurance that is presently available in Sub-Saharan Africa. It shows type of management, services covered, and whether there are deductibles and/or coinsurance. Table 4 somewhat relaxes the definition of health insurance that has been previously 5 One estimate puts the number of expatriates at about 30,000.
11 used in this paper, in order to give an idea of the variety of the types of "health insurance" coverage arrangement in Sub-Saharan Africa. For example, in Nigeria, five large parastatals provide extremely comprehensive care for their employees and their families, either through their own health-care facilities or through contracts, and the 2,751 registered private employers (out of a total of 8,794 registered employers), who responded to a Ministry of Health questionnaire, provided similar combinations of coverage for their employees and families (Nigeria, Federal Ministry of Health, 1988). The chief complaint from those employers who provided care for their employees either directly or on contract was the cost of the health care provided; it averaged about 6 percent of payroll for those employers who responded to the questionnaire. Also, many of the employers, who used contracts, thought that many of their employees were abusing their health-care privileges by toofrequent use. In general, these Nigerian plans cover all kinds of treatment, inpatient, outpatient, and drugs.

In Kenya, an estimated 2.1 million employees and their families participate in the National Hospital Insurance Fund (NHIF) that was established in an Act of 1967. Persons with a taxable income of Ksh 1,000 or more per month are required to contribute 20 shillings a month to the Fund. This 20-shilling amount has remained constant since 1967, with the result that, while only 40,000 persons qualified in 1967, inflation in wages and salaries had driven the number to 90,000 by 1988. Benefits include a fixed daily payment to the hospital of Ksh 200 with an upper limit of 180 days per year. There is no deductible, and the sole "copayment" consists of paying the difference between the maximum Ksh 200 per hospital day and any more expensive hospital care that is chosen. Only inpatient care is covered. In addition,
12 public employees have a fringe benefit whereby 2.2 percent of the total MOH recurrent budget is used to subsidize their use of private medical care; this fringe benefit covers inpatient, outpatient and drug care. There is no deductible, but there is a coinsurance provision where the government employee pays a coinsurance rate that varies inversely with the employee's government grade level. Finally, about 60,000 employees and their families benefit from group health insurance policies, the benefits and premiums of which vary by company. All of these private plans have set annual limits to the claims that they will pay for the individual, and these private health insurance benefits are in addition to those obtained under the NHIF, which is reported to have led to too frequent and frivolous use of covered in-patient services.

The kind of private health insurance that exists in Zimbabwe is of some interest because it very closely approximates the old Blue Cross/Blue Shield model of health insurance that prevailed in the U.S. during the 1960s and 1970s, with all of the consequent perverse efficiency effects that the model had on both the consumers and producers of health care in the U.S. Prior to the 1980s, Blue Cross/Blue Shield offered almost complete coverage of hospital care and generous physician reimbursement. Because of its service-benefit payment method, which was essentially cost-based, and paid retrospectively, and because of low deductibles and coinsurance, neither consumers nor providers had any incentive to economize in the consumption and production of medical care. Moreover, just as in the U.S., employer contributions are 100 percent deductible under the enterprise income tax laws in Zimbabwe, and, until recently, 100 percent of the employee contribution was also deductible under the individual income tax law there, thus contributing, at the margin, to the "overpurchasel of health insurance, and then to the "overpurchase" of
13 6 medical care, driven by the insurance. By "overpurchase" economists refer to any incentives that are offered by government or by any other entity that would induce consumers to buy more of anything, at the margin, than personal economic prudence and personal unsubsidized budgets would allow. The National Association of Medical Aid Societies (NAMAS), which is the national association for the non-profit medical aid societies (the analogs of the individual Blue Cross/Blue Shield plans in the U.S.) estimates that it had enrolled about 384,000 employees and their families by 1987, which was about 4.6 percent of the total population of Zimbabwe. The total enrollment was 224,000 employees in 1981 at independence, which indicates that the medical aid societies that are members of NAMAS have enjoyed rapid growth in their enrollees. Perhaps the major reason for this rapid growth is that the premiums charged (even apart from the tax deductibility) do not represent the true cost of care, particularly in government hospitals and in the large and sophisticated government-owned Parirenyatwa tertiary hospital, where NAMAS enrollees enjoy a large subsidy which is the difference between what it costs the hospital to provide a day of care and what NAMAS member insurers pay. For example, only 3.5 percent of NAMAS expenditures went to government (MOH) 1In the U.S. a great deal of analysis and empirical work has been done on the consequences and costs of this health insurance provision in the U.S. tax law. For a summary of this work, see Pauly (1986). With the reform of the Zimbabwean individual income tax law itl 1988, now only 20 percent of the premium can be deducted by individuals on their income-tax forms.
14 hospitals in 19877. The largest percentage, 48.6 percent, went to private physicians and dentists with whom NAMAS negotiates fee schedules, and which presumably does reflect the true marginal cost of private physician and dental practice. NAMAS estimates that its maximum market penetration in Zimbabwe would ultimately be about 10-11 percent of the total population, given the lower income of the other 90 percent of the population. The premiums that NAMAS member societies charge employers/employees vary with the income of the employee, so that some intra-plan cross subsidization among employees does take place. NAMAS plans do not use deductibles, but a copayment is required for the purchase of drugs.

VI. Analysis of the Major Issues in Health Insurance and Lessons to be Learned Tables 1-4 reveal the diversity of the health insurance arrangements that exist in Sub-Saharan Africa. These arrangements are both explicit (formal) and implicit (informal), according to the typology contained in Table 1. One can use at least five criteria for evaluating these different forms of health insurance. These criteria are : (1) who benefits from them; (2) the incentives for efficiency that are built into them; (3) the equity of the financing mechanisms; (4) their ease of administration; and (5) their political acceptability.

TPrivate hospitals/nursing homes received 15.3 percent of total NAMAS expenditure. The small percentage going to government hospitals can be attributed to (a) below marginal-cost prices in the government hospitals, particularly at Parirenyatwa, and (b) inefficient billing on the part of the hospitals. For example, Parirenyatwa is months behind in its billing because of an unworkable arrangement that it has with the government central computing office in Harare.
15 (1) BenaeficiLari. In the prototypical case of the Sub-Saharan countries, the majority of the population is informally insured by the Ministry of Health, with free care financed through the general tax fund, and if there is cost recovery, everyone but the poor pays some deductible and/or coinsurance. However, the distribution of health care facilities and MOH health expenditures is such that the poor do not even receive a proportional share of the health care. This situation can be changed by redistributing the given budget for health expenditures towards the poor. If such a direct redistributive policy is not politically possible, then government must resort to indirect means of redistribution. One way of doing this is to mandate formal health insurance for those in the formal labor market either through (a) requiring the employer to provide health care for his/her employees, or (b) requiring the employer to provide health insurance (both (a) and (b) being implicit taxes on labor), or (c) requiring the employer and the employee to contribute to a health insurance fund (the incidence of this implicit tax will depend upon elasticities of demand for and supply of labor). The proceeds from implicit taxes (a), or (b), or (c) then augment the total resources available for health care expenditures, and a greater percentage of the MOH budget can then be spent upon the poor.

Another strategy would be for the government to create a formal national health insurance for the formal labor market, financed by an explicit payroll tax. Again total resources for health expenditures are increased, and a greater percentage of the MOH budget can be spent upon the poor; the incidence of the explicit tax depends upon the elasticity of demand for and supply of labor. With either arrangement of financing, total demand for health care will have increased, and, depending upon medical-care supply elasticities, the
16 price per unit of medical care should increase. How large the new subsidy for medical care for the poor should be can only be a value judgement, unless the decision is based upon a cost-benefit analysis. The basic economic argument for the subsidy is that there are externalities in thd consumption of medical care by the poor<sup>8</sup> , and that employers/employees in the formal labor market are willing to bear the implicit or explicit taxes rather than having the preexisting MOH budget redistributed, in order that more care go to the poor.

The primary beneficiaries of the implicit (informal) kinds of national health insurance that exist in the sixteen countries where there is no formal health insurance seem to be government employees. In most cases, they receive some kind of preferential treatment over the rest of the citizenry, either in the form of not having to pay any cost-recovery fees or in getting some kind of discount, at least for hospital and physician services, but even for drugs in some cases (_.g.L, Ghana). Likewise, because most government employees tend to live in or near major cities, where most of the health-care facilities are located, their time-costs for obtaining care would be lower. In the countries where there is formal health insurance, government employees again seem to receive much more favorable treatment than the rest of the population (e.g., the government-employee fringe benefit in Kenya). In most countries with employer-provided health care or "insurance*, the employees in the formal labor market benefit, and to the extent that the demand for skilled labor is relatively inelastic, the employer probably bears the major burden of the aThese externalities in the consumption of medical care arise when society makes a collective judgement that the poor do not have enough medical care, because the poor cannot afford to pay for the medical care. Therefore society as a whole benefits from transfering resources to the poor in order to enable them to consume more medical care.
17 "taxo for this coverage and/or insurance. As a case in point, the employees of Zambia Consolidated Copper Mines (ZCCH) constitute only 6.1 percent of the total population of Zambla, but 24.1 percent of the country's total health expenditures are spent for them. In none of these countries, perhaps with the exception of Tanzania (see Vogel, 1987) or Ethiopia, where the two governments have made strong efforts to provide care in rural areas, de those in the nonformal labor sector seem to benefit from either non-formal or formal health insurance, both because they are either not covered or because they live in areas of the country where the government spends very little on health care. Also, it should be noted that public insurance efforts can compete with or even replace private insurance for some groups, which may not be a desirable outcome. There are ways in which private insurers can be encouraged by government policy (L.g., by reinsurance or by stop-loss provisions; see Vogel, 1989b), wlthout the government becoming a provider of health insurance. Employer-provLded care at least lessens the financial burden on the public sector, for an insurable group that is willing to pay.

(2) Incentives for Efficiency. Considerations about efficiency center upon efficiency in the consumption of medical care and efficiency in its production. Efficientcy ln consumption refers to having an incentive structure that **induces persons to** consume health care in an economically prudent manner (j1 .., **the absence** of Ofrivolous consumption). Efficiency in production refers to havlng an incentive structure that induces providers to take into account the economic costs of the treatment that they render. Efficiency in consumption can be encouraged by the insuzance coverage giving the correct insurance price signals to consumers. If only hospital care is covered by the insurance, and out-of-pocket payment must be made for outpatient care,
18 hospltal care wlll be overconsumed at the margin. Likewise, the insurance benefit strActure should be such that it gives strong incentives to use the referral system. The insured should also have insurance price incentives to seek out less costly forms of health care and not to overutilize the health care. Deductibles and coinsurance (related to income, if administratively possible) are usually used for this purpose.

Perhaps, more important than efficiency in consumption is efficiency in production. Fuchs (1982) shows that, although the patient-consumer initiates the health-care encounter by deciding to go for health care and to what kind of provider, the provider then begins a chain of treatment decisions for the patient that can have large cost implications. If the lnsurance mechanism reimburses the provider in such a manner that the provider bears no financial rLsk, then the provider will behave differently than if he/she is placed at financial risk for the treatment declsions taken. Pre-paid capitated forms of insurance reimbursement are usually seen as the vehicle that is most conducive to shifting financial risk to the provider of treatment.

Because most of the health insurance reimbursement in Table 3 is an openended cost-based type (e.g., ZLmbabwe), or represents transfers from ministry to ministry (L..j, Mali), the producers of the health care are at no financial risk, and therefore have no incentive to be efficient. Consumers of health care face low deductibles and coinsurance, or none (e.g., Zimbabwe or Nigeria), and they too have no financial incentive to exercise ordinary economic prudence in the consumption of medical care. Even when there is insurance, decuctibles/copayments of some type are a desirable feature to prevent moral hazard. Insurance, therefore, does not replace a user-fee system; there should always be some form of deductible/copayments.
19 (3) Eguitable Financing. Given that the objective of the formal health insurance initiative is to pool risk for everyone and to cover the externalities in the consumption of medical care by the poor (ie., that society as a whole benefits when the poor have more access to medical care, without having to pay for it), it would always be preferable, on equity grounds, to finance the increase in total resources for the OH with a progressive income tax, rather than with the implicit or explicit payroll taxes outlined in (1) above. Payroll taxes, particularly those with an upper limit on the base of the tax rate, are regressive to 'ncome. In the cases in (1) above however, the poor are not required to pay the implicit or explicit taxes unless they participate in the formal labor market, so that the implicit and explicit taxes in (1) above are not as regressive to the income of the different income classes as would be implicit or explicit payroll taxes that would be applicable to all income classes. With respect to equity in the financing of additional health services for the poor in Sub-Saharan Africa, we can assume that a progre sive income surtax earmarked for health care cannot be enacted for the same political reasons as why the preexisting MOH budget cannot be reallocated more toward the poor.

The contents of Tables 2, 3 and 4 reveal that much of the informal and formal insurance is provided by government to upper and middle-income government employees. The tax systems used to finance this insurance are, at best, proportional, and in many cases, regressive to income. Therefore, in general, these governmental health insurance systems can be judged to be regressive to income, both in who benefits from them and in who pays the taxes to finance them. Many of the private employer schemes appear to be proportional or progressive to income, to the extent that the employer bears
20 the incidence of the "tax" (premium) in tight labor markets for skilled personnel.

(4) AdMinistrative Aspects. Because the major policy goals of introducing health insurance into Sub-Saharan Africa dre to mobilize more resources for health care for the poor and to create incentives for greater allocational and internal efficiency within the health care system, a major design imperative for this health insurance is that it be one that can be administered as easily and inexpensively as possible. Otherwise, for a given amount of additional MOH expenditures for the poor, the implicit or explicit taxes that will have to be levied on the formal labor market will have to be higher, thus creating additional dead-weight losses to the economy from the implicit or explicit tax system used to finance the additional, unnecessary administrative costs.

There is little empirical evidence on the administrative costs of health insurance in the Sub-Sahara. The costs of administration of the Prevoyance Sociale in Mali may approach as much as 50 percent of revenues (Vogel, 1988), but MAMAS in Zimbabwe indicates that its member Medical Aid Societies' administrative costs are 3robably less than 10 percent of revenues. There are many practical problems to be solved in designing health insurance that is financially sustainable, including actuarial data on the costs of care and the -Amounts of **services** that will be d uanded (Borch, 1990).

(5) Political Accegtability. Finally, the design of the formal health insurance should take into account its probable political acceptability by employee-consumers, employers, providers, and government. If those employees/employers who are taxed (either implicity or explicitly) do not believo that they benefit from the health insurance, or do not believe that
21 the consequent freed-up funds in the MOH budget are used efficiently and effecltvely upon the poor, there will be taxpayer resistance and noncompliance, over and above that which would have occurred with a well-designed formal health care insurance. Likewise if the provlders of health care believe that they are not treated fairly and reasonably in the transfer of financLal risk, they will not respond to the incentives offered by the health insurance in an optimal fashion. Assuming that the formal health insurance is designed at the Ministry of Health, it will not become a reallty **and** function smoothly for its redistributive and efficiency objectives, if it does not find approval at the Mlnistry of Finance, in the Parliament and at the Presidential leiel.

# VII. Summary and Conclusions

This paper has attempted a survey and analysis of health insurance in 23 Sub-Saharan countries. Perhaps the most useful way to approach the subject of health insurance in Sub-Saharan Africa is to think about it as a phenomenon of income class and income distribution. Put clearly and simply, the larger percentage of MOH budgetary expenditures in these countries (with the possible exception of Tanzanla and Ethiopia) is skewed towards a well-defined smaller population. In all of these countries, the well-to-do pay for the "best" 9Due to the initial amount of opposition to the Medicare health insurance program for the elderly by physicians and the American Medical Association, and by the American Hospital Association, there was a great deal of apprehension on the part of the U.S. Department of Health, Education and Welfare on July 1, 1966, when the program went into effect. Officials in the Department were afraid that physicians and hospitals would refuse to treat the elderly under the new insurance program. Because physicians and hospitals quickly realized how generous Medicare payments were, given the manner in which reimbursement was done, they quickly adjusted to it. In effect, they bore no financlal risk in the program.
22 health care in the private sector, either out of their own pockets or through insurance policies that usually come from foreign sources, such as the French Prevoyance Sociale. The large majority of the population that is poor relies upon the MOH budget as an implicit or informal form of national health insurance, or upon traditional healers for whose care they must pay out-ofpocket. Because MOH per capita budgetary expenditures are relatively low in the geographical areas where the poor live or for the kinds of health care facility that the poor use, the poor do not much benefit from these **informal** national health insurance systems. Indeed, fragmentary evidence indicates that the poor spend a relatively large percentage of their annual income on traditional healers and on drugs when they are available (do Ferranti, 1985).

The data and analysis in this paper seem to indicate that the greatest beneficiaries, as a class, of the health insurance that currently exists in Sub-Saharan Africa are the relatively small middle-ciass. When they are employed in the private sector, their employers either provide health care directly or on contract, which means, in effect, that they are insured. When they are employed by the government, they usually enjoy preferential treatment under both informal forms of national health insurance and formal forms of health insurance. This finding is really not surprising, in view of the fact that in richer countries, such as in North America and in Western Europe, the middle and upper classes enjoy greater Zinancial and geographic access to health care, via health insurance, even national health insurance"'. Be that as it may, it seems safe to conclude that the development of health insurance 1<sup>0</sup> For example, in Sweden, where income is more equally distributed than in most countries and where there is a well-funded national health insurance, the Swedish government has a great deal of difficulty in finding physicians to serve in the rural areas of the north.
23 to date in Sub-Saharan Africa has not promoted greater equity in the access to health. services by the poor, nor has it permitted greater access.

When one evamines the efficiency aspects of the health insurance that is in place in the Sub-Sahara, it must be concluded that the forms of health insurance that have been adopted do not encourage efficiency for the most part. On the consumption side, many kinds of insurance d.o not have deductibles and coinsurance, and the most frequent complaint is that employees and their families abuse the access to health care that they have. In Zimbabwe, where private insurance has grown rapidly since independence, the model that has been apparently used is the one that existed in the U.S. in the 1960s and 1970s, where the purchase of health insurance is heavily subsidized by the tax system, where all kinds of medical risk are covered, ranging from hospital care to dental and eyeglass care, and where the insuree has no disincentive to use health care, even for the most frivolous purposes. Analysis of this model has shown its deleterious effects upon government policy objectives of slowing the growth of excessive health-care expenditures (Pauly, 1986). On the production side, we now understand the perverse incentive effects that open-ended, cost-based retrospective insutance payments can have on the providers of health care. There is no incentive to be efficient, and medical costs escalate. In one way or another, all of the health insurance arrangements studied in this paper pay the provider in that manner.

Reform of many of these health insurance arrangements will not be an easy task, simply because the redistribution of income is politically difficult. In countries where there is implicit national health insurance, greater equity for the poor requires that a larger percentage of the MOH budget be directed
24 toward the poor. One obvious way of having some of the resources to pursue such a policy would be to eliminate any favorable treatment that government employees receive in the health-care system. Similarly, more MOH resources could be freed in all of these countries, if there were more private health insurance available to those who could afford to pay for it<sup>11</sup> . Governments must carefully examine the regulator.y and incentive atmosphere to make sure that they are not inhibiting the development of private health insurance. Nevertheless, governments must also be careful that the kinds of private health insurance that do develop are designed to foster efficiency in the production and consumption of health care. The empirical research literature indicates that prepaid capitated health insurance fosters efficiency on the production side, and that deductibles and coinsurance have similar effects on the consumption side.

1 It could be argued that more private health insurance would increase the demand for health care on the part of the well-to-do who could afford the health insurance, and thus make the distribution of access to health care even more inequitable. This result need not necessarily follow. First of all, if the private health insurance is well-designed (such as being capitated, and/or only catastrophic), then the demand for health care by the well-to-do need not necessarily increase. Secondly, even if the health insurance is not welldesigned, the existence of the health insurance should bring forth a private health-care supply-side response, which, if the MOH budget is not cut back, should increase total national resources going to health care. Finally, if the well-to-do no longer use MOH facilities, or use them less than in the past, the MOH can spend more per capita on the poor. Therefore, depending upon the design of the private health insurance and/or the private health-care supply response, the poor may actually capture a greater share of total and/or government health-care resources than they did in the past.
25

# V. References

Akin, John C., N. Birdsall, and D. de Ferrarci, 1987.<sup>Financing Health</sup> Services in Develoning Countries: An Agenda for Reform,<sup>Washington, D.C.:</sup> World Bank.

Amenyah, Joseph. 1985. Prefeasibilitv Study National ,lealth Insurance Scheme. Ghana, mimeo manuscript. August.

Blair, Roger D. and Ronald J. Vogel. 1978. "A Survivor Analysis<sup>of Commercial</sup> Health Insurance". Journal of Business, July.

Borch, Karl. 1990. Economics of Insurance. Amsterdam, North<sup>Holland.</sup> Bruner-Jailly, J. 1988. Le Financement des Couts Recurrents de la Sante<sup>au</sup> Mali, Premiere Redaction, Geneva: World Health Organization. De Ferranti, David. 1985. PaXing for Health Services in Developing<sup>Countries:</sup> An Overview. World Bank Staff Working Papers No. 721.<sup>Washington, D.C.:</sup> World Bank.

Feldstein, Paul J. 1988. Health Care Economics, 3rd ed. New York,<sup>N.Y.:</sup> Wiley.

Fuchs, Victor R. 1982. Who Shall Live? New York, N.Y.,:<sup>Basic Books.</sup> Nigeria. Federal Ministry of Health. 1988. Report of the National<sup>Committee</sup> on the Establishment of Health Insurance Scheme in Nigeria.<sup>Vol I.</sup> Lagos, Niget.a: KOH. September. Vol II, Appendices to<sup>the ReRort of</sup> the Nati Comittee on the Establishment of Health Insurance Scheme Pauly, Hatk V. 1986. *Taxation, Health Insurance, and Market<sup>Failure in</sup> the Medical Economy". Journal of Economic Literature, 24 (2), June 1986: 629-675.

Vogel, Ronald J. 1987. Financing the Health Sector<sup>in Tanzania: A Public</sup> Exoenditure Review. Washington, D.C.: World Bank. December.
26 Vogel, Ronald J. 1988. Cost Recovery in<sup>the HealtCae</sup> Sector: SelSeced Country Studies in West Africa. Technical<sup>Paper Number 82. Washington,</sup> D.C.: World Bank.

Vogel, Ronald J. 1989a. Trends in Health Expenditures and Revenue Sources in Sub-Saharan Africa. Paper prepared in<sup>conjunLtion with World Bank</sup> Africa Health Policy Paper. PHRHN. Washington,<sup>D.C.: World Bank. March.</sup> Vogel, Ronald J. 1989b. "Cost Recovery in the<sup>Health-Care Sector in Sub-</sup> Saharan Africa". University of Arizona Working<sup>Paper. Tucson, AZ.</sup> November.

World Bank. 1988. Kenya: Review of Expenditure Issues<sup>and Options in Health</sup> Finalng. Washington, D.C.: World Bank. June.

World Bank. 1989. Zimbabwe: Issues in the<sup>Financing of Health Care.</sup> Washington, D.C.: World Bank. August.
27 Table 1 TyDology of the Forms of "Health Insurance" in Sub-Saharan Africa

- I. Government: Mandated or Voluntary

- A. Free health care for all citizens (Tanzania)'.

- B. Free health care for the poor, and cost re:overy for those who can afford to pay (Ghana).

- 2

- C. Social Security, or National Health Insurance (Senegal).

- D. Government employees health insurance fund (Sudan).

- E. Discount for government employees (Ethiopia).

- F. Other public insurance (Kenya).

- G. Mandated employer coverage of emplovees, either in directly providing health care, or contracting for it (Zaire).

- II. Private Sect.r: Voluntary

- A. Private insurance policies bought from insurance companies (Zimbabwe).

- B. Voluntary (self-insuring) risk pools (Rwanda).

- C. Employer provided, medical care directly in clinics (Zambia), or through contract (Nigeria).

'Countries in brackets are examples of where this form of "insurance" exists.

2Senegal has Social Security (the Prevoyance Sociale); no country in Sub-Saharan Africa presently has National Health Insurance (NHI), as it exists, say, in Great Britain, although forms of **NHI** that would cover fairly large segments of the formalized work force are under various phases of discussion in Ghana, Nigeria and Zimbabwe.
28

**Table** 2: Covereac of Health Insurance in Su-Saharan Africa*

|Country|Year|Population<br>Size<br>(Millions<br>(mid-1986)|<br>Pomulatfon<br>Covere<br>) Social<br>Other Public<br>Security<br>Insurance|d<br>by<br> <br>Private<br>Insurance|Totalt*|Percent<br>of<br>Population<br>Insured<br>(Including<br>Family<br>Mefners)|
|---|---|---|---|---|---|---|
|BurkinaFaso|1981|6.7<br>(1982)|Caisse<br>Nationale de<br>taSecurite<br>Sociale (CNSS)<br>covers<br>60,000<br>workers<br>in<br>private<br>sector**and**<br>government<br>emploo nt,<br>but no number<br>of goverroent<br>employeesis<br>given for the<br>goverrumnt<br>-ployees<br>covered.||||
|Burun.di|1986|4.9<br>(1986)|070,||.070|1.4X|
|Cameroon|1984|<br>9.3<br>(1982)|b||||
|Coted'Ivoire|1985|<br>10.2<br>(1985)|**Data**not**available**<br>**on nuWb**<br>peopleinsured,<br>but a smel<br>health Insurance.|**ers**<br>of<br>l private|||
|Ethiopia|19e|43.5|c<br>d|060|060|.001X|
|_Ghna_|1967|13.2||-|||
|Guinea|1985|6.1|Governrent esployees are e|xempt|||
|||(1985)|frm hospital adission<br>ch|arges.|||
29 Table 2 cont.

|Countrv|Year|Population<br>Size<br>CMOitions)<br>(mid-1986)|Poculation<br>Covere<br>Social<br>Other Public<br>Securitv<br>Insurance|d by<br>Private<br>Insurance|Total*|Percent of<br>Population<br>Insured<br>(IncLuding<br>Family<br>Mefbers)|
|---|---|---|---|---|---|---|
|Kenya|1985|21.2|2.1<br>.251'|.0cC|2 <sup>. </sup>4 <sup>h</sup>|11.4%|
|Lesotho|1986|_1.6_|No insurance because of (s<br>migratory<br>labor<br>force toS<br>whereeWployers ususily<br>pr<br>care,_and_(b) enterprise<br>c<br>local workerswith heaith|) lar§e<br>outhAfrica<br>ovide health<br>overage of<br>careprovided.|||
|Iadaacor|1965|10.3<br>(1985)|App rently<br>no forml<br>insur|ance.|||
|_Naald_|1985|7.2|||||
|Kali|1986|7.6|.250<br>200J|-|250k|3.3%|
|Mozbique|1986|14.2|||||
|Nigr|1964|6.1|||--|-|
|Nigeria|1986|103.1|1|.426|.426|.04%|
|Senegl|1967|6.8||-|--||
|Sudan|194|22.6|a||||
|Sjaitl|19W|.721|-<br>--|Private<br>irsurance<br>exists,<br>but<br>data not<br>avaitabte<br>fromsource.|||
30 Table 2 cont.

|Countrv|Year|Populatio<br>Size<br>(Milions)<br>(mid-1986|n<br>P<br> <br>Social<br>) Security|ooulation<br>Covere<br>Other Public<br> <br>Insurrnc _|d<br>by<br> <br>Private<br> <br>Insurance|Total**|Percent of<br>Population<br>Insured<br>(including<br>Family<br>Neffbers)|
|---|---|---|---|---|---|---|---|
|Tanzania|1987|23.0|--|-|-|||
|Ugnda|1987|15.2||--|--|||
|Zaire|1966|32.2||-||||
|Zanbia|1961|<br>5.6<br>(1960)||.342|--|.342|6.1X|
|Ziababie|1967|<br>8.7|.-||400,200|400.200|<br>_4.6X°_|

'The sources for the Information containfd In Tables 2, 3, **and** 4 are given for each country as the last entry for **each** country heading, in Table 4.

- **Am explained In the txt, in **saw** countries (2 L Zeire) private copanies my be required to furnish health care or pay for health care for thair employes. At som level of abstraction, this **my be** considered to be Ohealth insurance. Here, for purpoms of cornistency of treatment, "health Insurance" eans forml health insurance, where contributions (ether vowuntary or by law) are placed into an

- insuranmc pool, nd then withdraew to pay medical bills. What **the law** in Zaire does, in effect, ie force employers to self insure for its eloyees' health care. **Because** of space limitations in the Tables, **nu** bers of people **are always** given in the milions. Thus, for exaeple, the total population Burundi is 4.9 million, and the total ni 'r of people insured is .070 million (or 70,000).

- a mututlle de **La** Fonctfon Pthliquw. 3X of **salary** paid by employee and 4.5X paid by goverrmnt. Covers goverrmnt ployees and their faillies.

- b Report (see aources) ha an entry for Uationsl Social Inswrance Furd, data "not available".

- c Socalt Security and Pen ion Furd not inrolved In hse1th care-- long range plan to adopt ILO guidelines for health Insurnoe In Social Security plan.

- d Coverr_not *ptoyee receive 502 discowit at Goverr-ant facilities.

- Coverrurnt has been studying the possibility of National Health insurence (NH!) (mandated contributory) since 1985.

- f Equnvalent to more than half the urban population (NHIF-Nationtl Hospital Insurance Fund).
31

- Pubtlic service aployeas entitled to private medical care as a fringe benefit. Coverage **is funded** through MMt bt et. Cost to WM budget was Ksh 34.7 m t t ion in 1985-b66 or 2.2X of to_ta MON recurrent **expnditure.**

- h Does not include workers in private sector Wio receive medical care from employer or have employer psy for medical **care** directly: see Table 3.

- ± Pubtic fee schedule distinguishes between those with nd without insurnce, but no information on health insurwnce available.

- J Each goverreant ministry is expected to pay 80X of health care **costs** for its employee.

- k Social Security **and** Other Public Insurance are not dditive **because** tlic enployees belong to both.

- I Goverrwent etloyee end their fi_ilies receive free goverrment health care; but because cost recovery is so low, mot of the rest of the population **also** receives free health care.

- m Sanegal _has_ a **Social** Security System, the Institutione de Prevoyance Maladie (IPI4). No data **are avoilable on** the rLber of nmbers. Every fire with 100 or **ore** eplotyees is required to form an InstitutionZ that will pay most of the costs of outpatient m*dical **care and** phar_ceuticals **_w*,_**

- genrally, all of the costs of hospitalization, including deliveries of children. Firm with less then 100 eloyees can join together to form en "Institution. The actuarial construction violates most **insurence principles, because** it ignores the law of **large** mmbers, which protects againet **adverse** selection **(see** Vogel, 198).

- G Covernv nt e ployees receive smtll monthly dedution from paycheck (1$ for<sup>M</sup> regulara employees) in return for free hoalth **care at** goverraent facilities.

Doe not include workers In industry, mines, **nd** commercial farm; **see** Table **3.**
|||Table3:ContributionofHealth Insurance to Hea(thFirace<br>Rt Hlth Edit ^||||
|---|---|---|---|---|---|
|||ecurren ea xoernure. by Source<br>PLbiIC<br>|||<br>|
|||<br>Private<br> <br> <br> <br> <br> <br>|ShareofOut-<br>|ShareofPrivate<br>|<br>Shareof Forml<br> <br>|
|Comatrv|Year Currenc|NON<br>Social Security<br>Other<br>Pubtic 0ut-of-<br>Private<br>other<br>u<br>S<br>udoet<br>ludoet<br>Pocket<br>Insurnce<br>Private<br>Total|of-Pocket in<br>Total|Insurace in<br>Total|Pulic<br>insurance<br>In Total|
|lurkin8 Faso|1961<br>FCFA|3.06<br>203'<br>3 <sup>,60</sup>7<sup>b</sup><br>2<sup>,</sup>35 2<sup>C</sup><br>92U4<br>( s) t only avaltable for goverrmnt sqloyees.<br>binctudes: (I) OtherNinistries,<br>1,068; (II)<br>Foreign Aid, 2,349;<br>(Mii) tocal goverrmnt, 190.<br>Clcluis:<br>(1) Dru purcha.<br>2.298; (ii)<br>Paymnt of hospital fets, 54.|25.4S|--|0.220S|
|5luwi|1966<br>Flu<br>(millios)|127<br>489b<br>1<sup>,</sup>07<sup>0</sup>6<br>62ad<br>2.984<br>aIncludes:<br>Ci) NON 1,077; (Mi)NOE181; (Mii) NSA 9.<br>binclujs:<br>(1)Nutuellede la Fonctfon Publiqu, 476;_and_<br>(if)<br>ocial<br>security,<br>13.<br>CForeign aid.<br>iri<br>l<br>ud<br>**aamissim**<br>(210 Flu).whichare almost totally<br>financd by<br>out-of-pocket (210 Flu of 215 FBu).|<br>21.0X||16.4S|
|C_nroon|1963<br>FCFA 2<br>(millions)|2,140<br>--<br>331a<br>--<br>--<br>6<sup>,</sup>100<sup>b 28,571</sup><br>*Foreign assistance for recurrentcosts.<br>bio informtion<br>on private sector available for Ca_roon, except for<br>the IOOs that snt<br>the 6,100 million.||||
|Cote dlIvoire|1965<br>FCFA 2<br>(millions)|9,085<br>300a<br>b<br>**39 58 5 **<sup>**c**</sup><br>562<br>69.532<br>*CNIPS<br>(Caisse lationale de Prevoyance Sociele).<br>%sutu lle Gwwrale de Fontiomnaire<br>andcontained inNUbudget.<br>cOf this<br>xmont, 32,641 for drugs.|569X|.0811|043U|
|Ethiopia|1986<br>BIRR<br>(mllions)|**79 0 **<sup>**'**</sup><br>--<br>20.0<br>196.5<br>0.6<br>5.7<br>301.8<br>Govern,nteeployees receive 50 discount at Goverrtent facllities.|65.01|_.021_|--|
|_Ghab_|1987 Cedi<br>(billions)|5.5<br>--<br>--<br>11.0<br>-<br>2.5<br>19.0<br>iON erployees and trainees receive all carefree<br>and 40S of all drug<br>Issuedat asmple of hospitalsstudied<br>In 1988.|57.9X|--|--|

W
|||Tabte 3 cont.<br>Recurrent Nealth Exsenditure,<sup>by Source</sup><br>Public<br>Private<br>Share of Out- <br> <br>Pli<sup>Of</sup><br>Pit<br>Other<br>of-Pocket In|Share<br>of Private<br>Inurance In|Share<br>of Formt<br>Pubtlic Insurwmce||
|---|---|---|---|---|---|
|Countrv|Year Currenc<br>|_NMN_<br>Sccial Security Other ubtc<sup>ut-o-</sup><br>rvae<br> <br> <br>MdAt<br>*udbet<br>udoet<br>Pocket<br>Insurance Private<br>Total<br>Total|<br>Total|<br>in Total||
|Quine|1963 Sylis<br>5<br>(thound.)|11,820<br>--<br>35.000<br>236,000<br>--<br>--<br>789,240<br>29.9%<br>|--|--||
|Kenya|1964<br>Kenyan 1<br>Shilitna<br>(.11ll11m|232.2<br>109.0'<br>2 27 3<sup>b</sup><br>1,175.6<br>35.3<br>9 6<sup>.</sup>6<sup>'</sup><br>2,876<br>40.9%<br>w)<br>%NIF--hational<br>Hospital<br>InsuranceFund.<br>Includs:<br>(1)Appropriation<br>In Aid to NON,3.7; (ii) NH.icipalities,<br>152.6;<br>(lii)<br>International Donations,<sup>71.0.</sup><br>lnctudes:<br>(i) Nissians 29.3;(ii)<br>OtherM",13.4; (Cii) Private<sup>coqnies,</sup><br>53.9.|1.23%|3.8S||
|Lesotho|1966 Maloti<br>(thousand|20,936<br>-<br>3.122<br>10n726<br>432<br>26.519 61737<br>17.4%<br>s)<br>'Includes:<br>(i) foreign<br>Industry,<br>20.460;<br>(ii)<br>Foreign<br>private<br>Aid, 1,174;<br>Ciil)Local Votuntary Bodies,<sup>1.024; liv)</sup><br>Missions,<br>3,861.|.070%|--|_'-'4_|
|Madagascar|1985<br>FMG<br>(miltions)|13,693<br>**8**<sup>**, **</sup>**051**<sup>**a**</sup><br>13,921<br>4<sup>,</sup>753<sup>b 40.418</sup><br>34.4%<br>aIncludes:<br>ti) Other<br>ministries,<br>3,599;<br>(il)<br>foreign<br>aid, 4,452.<br>bincludes:<br>(I) Collectivities,<br>399; (ii) WOs.<br>934; (Iii) Private<br>enterprie,<br>3,420.|||LA|
|Naltae|1986mlawl<br>Kuacha(K|36,753<br>_-8_<br>_860_<br>3,578b<br>--<br>--<br>48931<br>7.3%<br>)<br>alncludes:<br>i) Value<br>of drugs in foreign<br>assistance**,**<br>6 000;<br>(bi)Foreign<br>medical<br>personnel<br>intechnicalassistance<sup>2,600.</sup><br>bincludes:<br>Ci Fees at MON facilities,<br>1,048;<br>(iI) Fees at PHAM facilities,<br>2.530 Cestimted).||||
|Mali|1986<br>FCFA<br>(millions)|4,025<br>3840<br>64 0<sup>b</sup><br>13,036<br>--<br>-- 18.081<br>72.1%<br>'About<br>50% of these funds<br>go for administrative<br>epenses.<br>bincludes:<br>(i) Other<br>Ninistries,<br>96; Mi) Foreign<br>aid, 542.|--|2.1||
||||Tadle<br>R current Health Exoendlture.IvSo<br>Publk C|3 cant.<br>urcee<br>Private<br>Share f Ot|h f Pi|<br>|
|---|---|---|---|---|---|---|
||||NON<br>Social Security Other Public Out-of-|<br>o u-<br>Pit<br>Oh<br>|are o rvat<br>|<br>Share of Formol<br>|
|Countrv|Year<br>|Currency<br>|<br> <br>t<br>Sudeet<br>udoet<br>Pocket|rvae<br>ter<br>of-Packet in<br>Inwrance Private<br>Total<br>Total|Inuronce in<br>Total|Public Insurance<br>ln Total|
|Mozabique|19l5|ueticat|--<br>-<br>MA<br>S<br>ACC0rdi,n to ource, donor contributions have<br>in recant yeors;amountnot knom.<br>lst recovery revnu s. In 1967. in the face<br>difficulties,<br>*<br>**,**<br>**nvmore**<br>coq<br>O<br>rhensive cost r<br>Introduced, consistins of tl) a flet one-time<br>cmnwultations (11) p ynent for outpatint<br>dru<br>Inpatient**fee**in urban hoapitals.|.-<br>-<br>754.7<br>7.4<br>been substntial<br>of growi,n finncial<br>ecovery schemwes<br>fee for outpetient<br>gs,**_w*_**(Mii)**a**daily|--|--|
|Niger|1964|<br>FICA<br>|4,455<br>-<br>4.0450<br>300I<br>*Includes: (f) Externl<br>assistance, 2,500; Cii)<br>(Off) Ninistry of Finance 1,090 (of<br>(iv) Others, 105.<br>binclucjs:<br>(i) Druss. 2,800;fii)Other. 200.|*-<br>--<br>11,500<br>35.2X<br>Niniatiy of Higher Education, 350;<br>uhichO1N0for foreign evacuations);|||
|igeria|1965<br>|Nair&<br> <br>**(mill**ions)|177.2<br>--<br>592.1<br>696<br>% 9b<br>aincludes:<br>(1)Stateexpenditures.<br>436.6; (1i)<br>bstimsted fr<br>OverandDenton(1968),<br>pare.<br>5<br>103.1 x 16 x 42.37 (population x11t1xavera<br>cssua<br>that only the respondents to NU0 qusti<br>s<br>**OCrnts***<br>colum In Table 3.|**74 9C**15431<br>45.3<br>Local governmentauthorities,<br>155.5.<br> <br>.14endTable 5.3;<br>ge eenditure).<br>ommare provide care;|||

**(mill** ions) 6 9 LA aincludes: (1) State expenditures. 436.6; (1i) Local government authorities, 155.5. bstimsted fr Over and Denton (1968), pare. 5.14 end Table 5.3; 103.1 x 16 x 42.37 (population x 11t1 x average eenditure). cssua that only the respondents to NU0 qustiommare provide care; s **OCrnts*** colum In Table 3. Senegal 1961 FCFA 6.890.4 _175.7_ 9,479.9 6,919.9b 4 **15 6**<sup>***C**</sup> -- 27,622.4 25.1X 15.0X .061 (il li fons) CIncludes: (1) Special budget for civil servants, 1,201.2; (11) External contributors. 4,530.9; (ifi) Paratatal expenditures. 1,52S.1; (iv) Local governent expenditure, 1,1791. bincludes: (i) Coummity participation, 425.0; (1i) leport of pharoceuticals, 6,494.9. Cincludes: (I) Hopital Principal, 2.294.0; (ii) Private doctors, 562.8; (111) Private clnics, 1.300.0.
|||Table<br>3 cont,<br>RecurrentHealthExpenditure,<sup>bySource'</sup><br>"Pilc<br>Private<br>Sh|are of Out- S|hare of Private|<br>Share ofFor_l|
|---|---|---|---|---|---|
|||<br> <br> <br>Pli<sup>Of</sup><br>Pit<br>Othr<br>of-|Pocket In|Insuranco In|Pubile<br>Insurance|
|Cointrv|Year Currencjmt|_MN_<br>Social Security other ubc<sup>ut-o-</sup><br>rvae<br>e<br> <br> <br>Budoet<br>Audett<br>Pocket<br>Private<br>Total|<br>Total|<br>Total|<br><br>in Total|
|tudan|1966<br>LS<br>(mllIa)|**MA**<br>**1**<br>**P**<br>**0**<br>-49<br>_7 _<sup>_'_</sup>_5 _<sup>_c_</sup><br>617.6<br>**aIncl,u_**LS5.9 from deductions<sup>from monthly pay of goverrmenteloytcs.</sup><br>_b^W_<br>re<br>;qof<br>highndtow estim-te.<br>5Expenditureby private firms.<br>**_"S.9/617.6_**<br>where5.9 is deducted from<sup>govern,ent *eployes--- see</sup>|77U6X|-||
|Swaziland|1984<br>E<br>(thoumnde|9.745<br>--<br>3,500<br>3.600<br>1.200<br>3,l00b<br>21.145<br>)<br>aInctudes:MI)Other ministries,<br>600; (Ci) Foreign essistane,<br>2,900.<br>bincludes:(i)Misions,<br>00;(1) Voluntery<br>organizatiors, 300;<br>(III) Industry<br>*nd mines.<br>2.000.|17.0X|57s-||
|Twnzanis|1967 Tanzania<br>Shilling<br>(millions)|1,838<br>--<br>3,376<br>b<br>5214<br>*Includes:(i)Ministryof Local<br>Goverrment<br>nd Cooperation,<br>1,358;<br>Ci) Office<br>of the Prime Minister,<br>1,112;<br>(iii)<br>Donations<br>of Drugs by Danida,<br>770;<br>(iv) District<br>and Urban Do eop emnt Levy,<br>136.<br>bAll health care at governuent<br>focilities<br>isofficially<br>free.<br>Users of<br>some mission<br>facilities<br>pay government-regulated<br>fees. Mny of the<br>feesare forthedrugs<br>donated<br>by Danids,butonly**at**mission<sup>facilities.</sup><br>The expwnditureaoutsare uninown.|||**_LA_**<br>'n|
|Uganda|1988Ugonda<br>Shilling<br>(millions)|62417<br>*-<br>43,090<br>290.000<br>--<br>14<sup>,8 </sup>61<sup>b</sup>4 10 <sup>368c</sup><br>*Includes:(i)Mulago Hospital<sup>and Complex, 35,093;</sup><br>(ii)<br>Ministry of Local Government.<sup>7,997.</sup><br>C3old. Shillings.|<br>7|-|--|
||||Recurrent Heatth Exzeriditu<br>Puhtc|Table 3 cont,<br>re. by Souwce*<br>Private|||Sh||<br>|
|---|---|---|---|---|---|---|---|---|---|
||||<br>MO<br>SoclotSecurit<br>OtherPubtic|<br>Ot-f-<br>Pit|Oh||are of Out-<br>|Share of Private<br>|<br>Share of ForLt<br>|
|trv|Year|CArrency|<br> y<br> <br>-L-et<br>Sudoet<br>Sudoet|uo<br>rvae<br>Pocket<br>Insurnce|ter<br>Private|Total|of-Pocket In<br>Total|Irsuracme In<br>Total|Pbtilc_Inumrnce_<br>in Total|
|Zaire|1986<br>(|USS<br>t<br>milllaw)|O<br>O<br>Alaocovers<br>health care of goverrsnt<br>biecluddal:<br>(I) Privte-sector<br>firm.<br><br>(II)<br>Donrs gn 160s,sep|41.0<br> <br>qplaoees.<br>14.O;<br>rrate<br>breakdowi not a|154b<br>vailoble,|205.0<br>10.0.|20.0X|||
|Zmbia|1981<br>(|Kuwaha<br>millions)|<br>.s9<br>*-<br>30 <sup>.</sup>9<sup>a</sup><br>Z2ianCornolidated CoperNines (Z|199<br>CCN),thestatemini|4.5<br>ng corpor|128.2<br>ation.|15.5X|--|24.1S|
|Zilabwe|1987<br>|ZS<br> <br>(mi<br>ll ions)|_310.t8_<br>_-l_<br>99 32<sup>b</sup><br>aCentrdl Goverrment.<br>bInludos:<br>(i)N.icip.lities,<br>25.00;<br>CIncludes:(i) Church**missions,**2.56;<br>(111) Voluntary Orafniztion|63.90<br>105.00<br> (ii)<br>Foreign A"ists<br>(ii)<br>Industries,<br>NI<br>s,<br>4.50.|5781c<br>nce<br>74.3<br>nrw, Com|636.21<br>2.<br>erciat|<br>10.04X<br>Farm.50.75;|16.51X|--<br>w|

*Inciude. only recurrent _expnditures_ end _exclucs_ ependitures on traditional mdicine for reasons givYn In text.
||Itbl<br>4<br>Chorwter,st.cs<br>of ovoith<br>Inscr<br>e r,-se,r.,|Uric||
|---|---|---|---|
|countrn|GrolO(s)<br>Ilaw of<br>Percent of Inpit'ont<br>Uapottnt<br>_Provntive_<br>tUt<br>of<br>AbelMt<br>Uf<br>P*I<br>foear<br>Co,orevO<br>_owesot<br>*tr<br>Poewtioten<br>co-<br>Care<br>C-,<br>DMUr=t tro<br>te<br>Preuo<br>Prorl$|oIrta<br>C r_Ont<br>Odectibig<br>icdg%|Croe,h<br>tiShurt<br>ofSt.|
|orite<br>tro|toS=<br>1I0<br>Private<br>rimIC<br>60.000<br>Limitd<br>to mlcot<br>werwntures<br>n,<br>tiplo<br>D(oatt.,<br>varies<br>torer. in<br>workro<br>In<br>tito<br>ittfie.<br>on<br>to oCaetiwt<br>_of_2.51_of_<br>With<br>fase.<br>privtat<br>Iinjote.,<br>Nid to the prouiion ofnootwte.<br>.010ev.<br>motor<br>nd<br>setor;_,sovieas_<br>_fo_<br>_bu.ficiar,_<br>Imitlo.<br>Itn<br>psld.<br>110<br>wit<br>nr<br>tin<br>tow.<br>Setwr<br>MSt<br>Senos.|203|the otS<br>cover.CO hs<br>_norto_<br>i<br>both_teh_prl<br>te_tOd_<br>_pktIC_<br>__e0t4_<br>_eOOWD_<br>or,tr.<br>In_pt e..te_mtor<br>_wiN_203 sIlt.im<br>fCPA tout<br>.<br>,.1uz.<br>ft....c,.I&<br>tosio tosed.cst.~tCor<br>ed<br>disoliti<br>d<br>to ot9apZtinri<br>injntlos.<br>finrciie<br>la Mt<br>through<br>Z51<br>Sc<br>am:ti<br>fre.<br>"Wlss<br>podLe<br>Source tle,<br>CoLts:<br>ISetth<br>_Nd_bolitti<br>Soot<br>a<br>tll..<br>SUNdorb._1002._|
||*lnItUtKodue.irdtTro,It<br>mm tntr5*god<br>(corItrtbttoret<br>ewia<br>afrttho Infteorimt<br>I.ro<br>Is et_manthis<br>M.<br>NW. "M.||Otoff<br>foroloot 5st.<br>Isothr.meIth Sear-cos<br>peoritPrtit.<br>m.<br>tM.|
|BiodI|biwt.e<br>196<br>Civl t<br>t<br>41 iC<br>**.1**<br>F."<br>I f<br>oe<br>tooI<br>teo<br>Per.<br>**3 o**n<br>_n_<br>f<br>vol<br>de14towtlen<br>_Serwns_<br>Employed.<br>ctelry.<br>.tth<br>P,Mqion.<br>Nd<br>salary.<br>forite..|**_e*-_**<br>_2Z1_<br>SO<br>496.0|_Th._O_ta-to_<br>or.<br>bo.<br>IntoitO<br>forctilt<br>_tntt<br>Nd<br>thoir<br>_firto_<br>_No_Ce. Of<br>_t_5<br>_th_be_gemnts_<br>_mtt_<br>totitiu<br>oePtOYO**o**f pore.stU.t_we_comecialtfire..<br>ISo i"Oionce<br>is cerrently<br>fti<br>.csttly t*oU.<br>Sult,<br>.. tiv<br>spap ncdin<br>_USS 27_por cepit. on<br>c1hit<br>_M<br>Ndmt<br>b<br>M<br>t<br>r_mtnin<br>popite10.n.<br>Sorce:<br>Staio ApprolI<br>Report,. boNdt<br>Ptaputt.n<br>Nd foIth<br>Pr.ojct,<br>tr,<br>s.<br>"P.|
|Ci'ron|Th<br>iLesOsc_<br>to indleate<br>the:t ther<br>laA<br>e al th<br>tnmwu<br>tIn Iwo<br>,<br>fcpt<br>for the<br>tStionst<br>S.0st<br>tnurnc<br>fun<br>for d,icb<br>no dege exists.||_Snp,osedy._<br>the.<br>Is_a_<br>_iottio1t_$ocit<br>torfitoa<br>Fad.<br>att<br>noduto Ooi.tS.<br>t;cuc:Ctmoroo,. Oeth<br>Nd<br>itjitl0hetor<br>Rovish.<br>hector.<br>tNtt|
|Cote difroflr|1. Calm<br>Sottutetde<br>PraOV-o<br>Societe.<br>2.ktitotte<br>_Cerwte_<br>deFP,ttuntFtr.|Sot.<br>of thIs**tsn**<br>preently<br>ortamttttle<br>_for lInswerno_<br>tmse 1. 2.5.|Sorce:<br>*. SOcitlot<br>etG. oeercb.<br>inelts<br>di<br>*stt<br>de<br>oCat.<br>cifni.sen~t<br>deir<br>Forcti.onh t. R<br>t<br>Misslion,<br>n tot*<br>torIl<br>sotl0.1WOt2ims,_Pewtito._|
||3.<br>tiberm<br>private<br>Itnuswnc pltn.<br>inctdin<br>tao grsgp potitle.-<br>_for_profe.loCet<br>lrmp;<br>Peres<br>nd<br>156,000<br>Aparttty<br>**_Pe.Itv._**<br>Fer dovell.<br>(b<br>itndivlamt<br>policti.<br>Proa<br>Nd<br>250,000-<br>A4rr<br>ntty<br>**_lrity._**<br>300,000||S.Wogst.Cei<br>**Recovery**in the 0.5th<br>Cue Sector:stt<br>Country Studt<br>Iein<br>Int<br>Afits.<br>fty.<br>S<br>o00|
|gtoipie|tthteipln<br>1WOPrivet.<br>Privete<br>.006<br>.001<br>Tee<br>_Te_<br>1V"<br>Ye<br>fity<br>230**gint**<br>Insuraer|Lor<br>-l t. rn SrO,<br>0.8<br>pre vsi.<br>Ndr<br>w<br>imesi<br>ISIotS ps r Veer.|oi<br>cordstiil<br>i<br>Erovo.<br>Lth9i.po<br>**_plno_**<br>it<br>iom<br>t<br>thoILOWiftlirWi. to<br>t501e9Lp<br>felitth<br>i,rit<br>bt<br>itte<br>sitOin<br>its<br>Soc1ial<br>-usyNd<br>P-,<br>Fund. the_fIbiepim_<br>**_tlceIncer_**<br>cow"<br>**tim h"o**eceired<br>**w**<br>**5le**SitiinstrOti<br>v<br>.<br>tbetlt<br>tfre<br>t<br>_MCI_<br>_m.reu_<br>of peapte.<br>srurce:<br>toet.<br>R-ier.,<br>itttipie.<br>AStuidy of<br>tbeLh Finitin|
||i3unftr<br>-. 6<br>coRtsidrtion.<br>sota<br>sotl contributors<br>IcIidnlude:<br>t1) 2iC-O0 ttretnd<br>Inrdnpdmt<br>coco<br>farmets;<br>itt z-2sotkihmod<br>tin torlt<br>lot<br>erorst;<br>oilt)<br>Mthotund<br>cvtAI N<br>t.||ImploTverprovide hah<br>CV,<br>plo".tor<br>Wproif,<br>bt<br>thoream<br>Mn<br>datifOta_tht_<br>_subec._<br>_A_<br>ot_J_vIwDry_1._IWi*M--<br>tplore<br>s<br>Nd trni<br>otk hav to pae th[<br>Mtt<br>tCet of<br>**ei,**<br>that the,<br>*r.ef<br>1t b<br>sitcthr<br>ruYf s"Jecttocet<br>recoror.y<br>S-coe:<br>GCrePopul.t1on<br>N"th<br>a<br>Itil<br>CUt-10S Ct-ftl<br>hetmrw.<br>to,<br>Nrd_it._COgI.<br>ti<br>eto*<br>vtri<br>**t**h<br>it<br>tb<br>Core SOcto<br>1t9.|
|Eisn_|Nonetattls.|S"<br>exist.|C,or,orient<br>-*-r<br>ore<br>or,o,6005**5**ivosfb<br>n sutrancesystl<br>thlt<br>.Ot,<br>the. ftre<br>C<br>osit<br>oi<br>chares<br>(Itroned<br>_o<br>nr,<br>nS<br>trfte,<br>bhetor,<br>Nd<br>l<br>_NW)._<br>Sole-co tou.:<br>Po,ulsto,n,<br>"etch_tao_<br>_Sutritr.on6etor_<br>o,i..|
ItCi 4 Capt.

fino1 led

|Cotetrv|fino1led<br>C<br> <br>4r-p(f)<br>typeof<br>PercentIOf irtteint<br>Cluttptsot<br>P<br>*p,r<br>leer<br>C<br>e<br>Mlt<br>P<br>StW<br>_C0_<br>C|CwIts<br>o<br>tve<br>ret,,ww<br>unilt<br>at<br>klS<br>Uir<br> <br> <br> <br> <br>|tota<br>|
|---|---|---|---|
|Uterro|<br> <br>_.e_<br>are<br>liwe<br>16<br>**P**<br>ith<br>_PUSic_<br>2,100.000<br>ye<br>Nk<br>|Cr<br>Pre<br>_oA_<br>nrotlmtt<br>Pins<br>Pr,<br>to<br>_It in_<br>e<br>o<br>oi 20<br>Vrfa<br>m|0eoer<br>ooXt<br>Ce<br>t<br>OMtle<br>*o<br>centt.<br>Nd<br>D.C.<br>ofDot<br>f<br> <br>* <br> <br>|
||faskable<br>Itom of<br>mid.<br>*olnargolti teiWISt_affijad_daily Pa)iNtt to<br>ptel<br>oflW%<br>0 fotr no eye<br>per<br>yeW.<br>tile<br>oteor<br>*1_<br>beepitota.<br>bA In otsr.<br>patiNd pops theblowdi fatwone.<br>eA<br>It<br>1000<br>jle<br>Ps<br>IC<br>e<br>ty<br>sTM<br>CIepIt<br>9xidewo5<br>too)<br>for<br>jr323e<br>ddicoS<br>"ari.<br>l_Y<br>wis<br>s<br>.<br>Printe<br>Ptui<br>1006erivet.<br>Priytt<br>i0.00<br>l41<br>lea<br>(CA fewI<br>mo<br>*"O|<br>_<br> <br> <br>y<br>*.tostol.<br>ItWe<br>Tes<br>lye<br>Govelrmet<br>0<br>a<br>ImPlaoyw.<br>yes<br>yes<br>CrD|ug<br>lo<br>109.0 Suacez_A":_<br>aft,"_<br>oif.feittwE<br>_ltea_<br>NdMtienc In<br>alkth<br>6 nrmitk,<br>m.<br>imS.<br>toso<br>Uo<br>Koh27.12<br>Thig I<br>rftee<br>t.et<br>IprSaN<br>2.2COttoteal<br>r"Urrrt<br>btW.|
|COeotbo|<br> <br>ye<br>fIeNd<br>Nd<br>trove".<br>am<br>tS01|**_*ntwsme_**<br>f~ or<br>r_Y0-<br>sworive.|woriOs**0**<br>terin<br>br<br>AtprIrats<br>plate hbe<br>*t<br>~I<br>lmits<br>to Cl*fM<br>by<br>campoe.<br>plY.<br>PritcY.<br>_IWdOPber_<br>te<br>I<br>r<br>_Sit_<br>_a"_<br>ealttot<br>to those<br>0tn.d<br>r<br>Sb<br>ledto e_rW<br>cuuptliS<br>_ot_Omeerd In-petlant<br>eae.|
|<br>*|<br> <br>leeotllo~ ~ ~ ~ ~**~**<br>~<br>~ ~ ~ ~ ~ ~<br> <br>|~ ~ ~ ~ ~ ~ ~ ~ ~ ~<br>|U"Ith<br>6,a,urenc<br>is<br>opt erated<br>bymW**rnl09**<br>epgatirt<br>~ ~ ~ ~ ~ ~~4<br>rIfS tni_f_SElw^e<br>R<br>_enit<br>InL*ecth*OrNderMr&It<br>IV 4<br>utoiSO<br>d<br>bMS tlfS<br>.etb<br>dake:tp.q<br>(lawce,<br>p. 17).<br>thIn isply<br>Oatodo<br>_nrt_thatentorpr_ise_<br>_pwed a._<br>lmw o el<br>orel<br>W<br>for<br>tailr<br>lE<br>IS-tno-do iOe<br>(In<br>r<br>In<br>fat,'<br>sk"<br>so O<br>erM<br>bl-d5).<br>the LoOWSho Ct<br>Dtrk<br>SSetc<br>mdicat<br>Led<br>2cbmSe cie_ ed to<br>_opeLt_<br>CMrONa<br>Rin4l).<br>_Solibl'_<br>_Ald_1eo<br>Ctt S40AP to<br>operte<br>Sint ote m NW Itortr_d.<br>00|
|ftwcr|AwraitSy or tofSS Sesarma.<br>~|eAppttll|mormalew<br>sitel:<br>ftadtOe:<br>P00ISitatttNd beotti hetorIt"'Gis.<br>~9e1ereruc.<br>attly.<br>1<br>*00.|
|met|Metl<br>g lb"<br>is<br>O Ouilth im<br>e in>tw<br>Sothere Is or bea5tit<br>dtl_.<br>SI,Naleel.<br> <br>etltSC<br>1000 *<br> <br> <br> <br>|iCt|Pria<br>1<br>dlr-2pratp<br>"1e.salted<br>**t**ogbokrIn<br>mWdnical<br>iw'<br>Snte<br>bt<br>r1<br>iar<br>I.<br>**rMt**r<br>.<br>n<br>th<br>Privtet<br>eS-tinet<br>nAt<br>S<br>iR t (POW) preniet<br>abut45of theceriey'.<br>aeatohpervices.<br>Pli<br>to_ckw09_<br>related. Lecaloorowint<br>in61trlllaid<br>I.<br>aepslelo<br>mw<br>**as**tlYNW.<br>police,<br>2lattO<br>Nd i*rcltrfot<br>prwida<br>damstiew<br>_Pd_pr tl<br>tlv<br>sarviese<br>for their<br>atolmee.<br>gomld catmba<br>oltce;<br>taf<br>e<br>**_saitnl_**<br>_Snt,_<br>etialm tacmdFNdlyeamlh<br>Project, Peleaury. 199.|
||<br>..<br>IC Nd<br>Piilic<br>200.000<br>3.32<br>lea<br>lea<br>eagtional de<br>Private<br>_PrWAepWe_<br>NOwtor<br>Necial<br>(tell).<br>w<br>Nd thelr cath<br>im<br>Each<br>P%gotic2t',hO<br>261<br>Ien<br>las<br> <br>|lTM<br>loo<br>Wy<br>CeII<br>t Nwla<br>**Verl**<br> <br>and<br>cm,trlbaes with<br> <br>FealSy.<br>asof<br>eeiwy.<br>i<br>swlame,*<br>eatey_for_<br>pert S<br>r<br>at tell.<br>l<br> <br> <br>|CSwopVoided freeItt<br>380<br>Secuse 4rupare rarelyavailale<br>lnixi.lIc-sector<br>fecSSStln<br>ellIM Irdatelal<br>andillScISPeca._patiwntswAt_owthe.litprivot*_moromt._<br>ndicOl ciSnics.<br>_Source;J. *rune-Jaility._toFSiwkaem.tde.**_Cautte_**_9wrents_<br>ditSont*tl_OMe_<br>Nel, Pritoare NcKti.<br>**eqtOW.**<br>_1ON._<br>|
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||livollyd<br>roetel<br>rype<br>of<br>Vccontol<br>ci|i nrrz 'z<br> <br>_Iat_<br>mn|5¢. -- eu<br>S.~t. ".-p<br> Ottnt|cov od<br>~<br>_Tilt_b<br>4eert.<br>Covered<br> tl<br> <br> <br>|||
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||<br> <br>.<br> <br>|||||Unlike in _r<br>Afrrlrn cnuatrm,t tht_pre_wwtt<br>_Is_<br>relatively offic on.<br>Theallocationof rr4macewithin<br>the heath**eyI0m**S_ bewwetly**w.aimtia**with**stated**<br>**aoeeftintt polricieS aclzlre**<br>rtc<br>P<br>_ed_prmmtl_<br>ectovitlo.<br>iecwrmnt<br>tmdlmeWetiret from 10.0<br>PerCe t<br>oeWn<br>tU bket<br>In<br>9110to 3.9 Pwrcwn in<br>i9.<br>des to strins**eiLtu**<br>9KKr .<br>Smoa: Stotf<br>etaelt_ROpt._<br>_<br>_im health td<br>IwPritianProiect t pt_<br>"M.|
|wi4-<br>|**meT.**rwa<br>to beMn**elth**_Itmuwe Inslow.<br> <br>|||||Souce: staff<br>I Operelcti**I**<br>**t. slow**UMith Project.<br>February.t9ub.|
|tbrbs<br>piv"tll.<br>pereetal.|(1)<br>atlinwt<br>1<br>1<br>**Stoff.**d<br>**Isoatal**<br>1.5i0<br>_InwAtuma_<br>elf.._med_<br>Carp.of<br>leaidrtn<br>algali<br>_%nm W._<br>(Emic).<br>CZtLttil<br>1<br> <br>|**1T**<br>|TM|**Tom**<br>**ln**<br>**eter-**<br>**3D0Wt**<br>**staff--**<br>peid by<br>**permtatel.**|**Om**<br>r|**Om**<br>**_6i000,0_Staff admitspebotWe1* at of**<br>**. mtiflem**<br>_md_children In<br>ordw to eolid**abuses. eiON amu**_aMi_Seingic hoeitsti.<br>ovoe<br>**_t._**_a_**at**mekalds. fw adissosw miOitd<br>ivat.<br>All<br>othar mdtoai aervice.n ae tabtirnd f.m rtwerian<br>**Sivy**<br>Corporetim. eesptalwhich cbgms**aettlias**<br>fme ofto9per<br>vIsit.|
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||g<br> <br>sa,<br>r_to todt<br>22.000<br>**ports**<br>wife,_med_<br>oheruo.<br>ry<br>e<br>lodrcn<br>(iet).<br>mea. is.<br>**(01 eigi.**<br>**1a**<br>**Staff**_mdd_Pre tati<br>*97<br>1|TM<br>|Ta<br>|Tea<br>Too<br>Wys*<br>5272.72<br>pK staff--<br>paid by<br>pormUtetl.<br> <br> <br>*|st|1tre,<br>6,000,000 eIPA stoed**thewe**of retsars<br>atthe_md_of 114. do to<br>rIsrwe tcs.<br>Sm the autority rne Itsowaelinic_nd_rdfor-<br>stmeen cat_m to<br>1<br>nD hlrtt<br>hepitalsUdtheUtrb<br>uSntilty<br>rtecdkngt spitel<br>tilTs).<br>W|
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||is)**Ilwa**<br>"9OK**staft**_md_<br>**ParmtOtel S5.01i0**<br>*Sily<br>1 tly.<br>taldr n<br>**(ti).**<br>_r<br>i<br>_mnd_<br>_.me_cetwrtd.|**Tm**|**tea**|**1m**<br>**1e**<br>**Oqetetwa**<br>**Z212-U**<br>pt r<br>t--<br>goldtre<br>**pernitok.**|**am"**|dem<br>9,900,O0 P.reicars**donttrm.tbt net remst.lt**slad .<br>mCStmsty<br>hdv<br>Its omClinic.<br>eubealsi on_ian<br>ttilizatlon<br>of Its<br>tAdicat psonttp t,waichet_ream tndrb_at 1,tA2, ela to<br>control_of Mnt_<br>_pnt_MedrnerO_0_<br>tut1WaWWe.|
|PrIvate|2751<br>3952 VIb<br> <br>|||<br> <br>|||
|<br>_CANi_|,<br>am<br>Private<br>30.3T<br>r<br>__._<br>gWtOP<br>rsp<br>m to<br>e._i<br>aptnttmirm<br>muto<br>of<br>**t.itarted**<br> <br>priv"e. IlnC<br>**(1,3.)**<br>In<br>|Uth.|Tea|Tm<br>Tms<br>uofe-<br>320--<br>i<br>oree<br>ewea pW<br>*tstff<br>fat I per<br>"w.<br>or<br>dte<br>v.S7 tW|Uarte.<br>1rpmde|Swim 45,0201503 Ihatr we1.7%sreaslerod paret. utorwos in *ib-cs_mt_<br>(8.5e of<br>thoseMew-y<br>hn.**s told of**1,162.254 epl-tesm r._an_<br>total<br>averaae of 132.2mroye_<br>per firn). In**t9J,**the**it2l11**<br>pirolt)<br>tt<br>aet?,400 mIlUvwlrs<br>to priveteWoversmed Smd<br>forCM<br>**a rp**<br>**rote of**37.2n (2.751). Of thoe. d7misstart<br>t1031<br>etmitd<br>in-hotn ere.<br>1,g0<br>_loers_<br>tmd**pritvet**<br>ftras that<br>_rrmoImmts_andoetr pra_sca._md_I'M29 Glow<br>_,ebraoad_rtdpeea<br>in pt<br>orIndots<br>The a<br>Noarb<br>cast<br>to thi<br>_os_hospit<br>dal<br>tewa_1t27.00._<br>**_qt_**<br>**lintm.**|
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|si_ls|lelth<br>Inearettn<br>In<br>r_050<br>c<br>W<br>_fe. tmo_sanre:<br>(a)a.<br>**_UPSwd_**<br>(b> prlet<br>inurwanc.<br>go_dmwtatiUt_<br>Ispreewaly<br>oveltoile<br>far<br>tho IPS.<br>privte<br>Iirlaume<br>6Spervulv<br>_<br>t<br>a.<br>me0l050<br>espetrlco toasterd**_Ire_**a<br>Infe Smegt.<br>I<br>I.<br>.sutttne<br>ofgAlof<br>twerly<br>_so_**to**fleuSM<br>ta. Spttl<br>Princlipl,<br>ha eadBt<br>we<br>,sIIblt.||||T,e In<br>requires<br>a AScaUibwt.-<br>U th<br>pfl<br>at<br>=WOar<br>old<br>Iboro<br>b9r).<br>_thew_<br>_is_nodatS POsaiy<br>_ea_<br>_ble_<br>as thw rm.<br>of fIampeople<br>Urol ied ear Utn t1.<br>ttai<br>of the 101.<br>_Sorce:_<br>SlottAprsol<br>loor.<br>11w t brat<br>meets Project.<br>t_r.<br>1912**_Anl._**dva<br>tlet<br>eMt<br>in a.<br>oalth<br>Cre sector. Hey, 91.|
|am"|No<br>IN1<br>Atd<br>P1MT<br>intldtleoO<br>Co.evano<br>**featltm**t<br>'Wlooeo.<br>hosItat b|N otn<br>lw ma their<br>_trofA_<br>It of<br>o free Cie"._11_Sf**_.5_**<br>SOlary<br>oba for_wes_tam of stay.|rwieS<br>a<br>Wtl<br>"MeTe.|.|L5.59t<br>to<br>CD O<br>tinwacil<br>dffflcutifm<br>It_"M._<br>_rad_<br>_evwreat of_<br>privet#setr<br>tj.<br>"U.<br>**3**priat.<br>**hepitaf**<br>In_Chotams_<br>area;in191. 15 prI"est hnplto*a.<br>Sauce: st;n:<br>Poplatonttor..<br>elth<br>ta<br>arttlm<br>Sector ZatUt.<br>JA.<br>19.°i|
|dTilmd|Sodato otellable<br>frm<br>_sorace._||so**date**<br> <br>Souc.|_lo<br>blte fr.|sarcurce: r atnl<br>_Ps. letea_<br>_mnl_<br>NWSmith seor<br>ReAim.<br>Hey.<br>1956.|
|**fatle**|the<br>tonoheaith isarme<br>In *maint.||||ITossn's br<br>nM ilth<br>Insrance.<br>Par tpitt<br>hItb<br>*4pmdiltv<br>ha<br>ca0tt,end<br>tode.tts<br>_driA_<br>_al_<br>_thoS._<br>deitpe!<br>SDsIa<br>(arg<br>dorwiau<br>of paeM<br>itcots.<br>TheWTis bcaint<br>IenreMlr<br>ly intUrete<br>in<br>trm<br>of<br>otst<br>ecwry.<br>Saito:<br>_l_nunim Popetlati.<br>1o:i1 N<br>Mttrititn<br>tector<br>St...w<br>O.aar,<br>ri_<br>_matd_**.** 0qIt.<br>SImlaw<br>aT]1<br>Iert4Sentesr<br>In Tm<br>:soms.<br>A**01541**SapmItAre<br>dlev.<br>De~r, 1967.|
|_~v|eIh,<br>is<br>no<br>_Itbt<br>Irwrnt*<br>in Listck<br>for<br>tM<br>lndidoo<br>poplaion.|Plrl"to|||ut<br>_illInswr_<br>_"1_<br>dor<br>reaftlfwT<br>_NV"_<br>SfCmnaty<br>1<br>for thooe _lofa<br>d In IntmlndisU<br>rt<br>5J.<br>a.<br>Com).<br>60 for T1 ItAGWAl<br>ponlettn.<br>piv"to<br>hIt<br>I<br>r<br>i_mwe<br>_hat OK_<br>_<br>41<br>sarr.<br>of**_tinrerRio._**<br>The heIth<br>bromi.<br>tdo dt<br>"let<br>_f*r_<br>Me Wrltois<br>ott nantl<br>**lae_**<br>**rdft0U Sld.**<br>gaff";<br>i.<br>**Lee,**_V._<br>_Jtl Ca_<br>S.'two.<br>The Clot_ma_Pia<br>lro<br>of**oet**<br>**th**Service<br>to<br>I<br>mrJI .<br>_<br>tr.<br>1".|
|Zebr|Committed<br>SIM<br>Prlste<br>Private<br>7.2<br>22.42<br>too<br>t_<br>t_se.<br>Sector<br>ndpfSpoea<br>_maty_<br>**fttean.**|**tye**<br>**_Yea_**<br>**la**<br>**Pern**<br>0<br>Etrmd.|_M1_|**"0t**|14.0<br>dy t_a._storwa_<br>**we**rspirred<br>to**tutta**<br>heath Care<br>W<br>pay for thea_bdathcoe_ofTair _opte.<br>_In_11,<br>tS<br>of<br>r_O.s<br>Ioewwe<br>Inathe pr<br>**srtter**dt<br>**far hel th**<br>rew. PrIvet.aw<br>i<br>**msepre**<br>emaltse<br>"Mr**M1**pepswut.<br>**omlS**no.opwdbtse<br>we.10.33.<br>**Sarc:**<br>**Zrebr:**<br>**roputatUn. Smte**et<br>n<br>rtltiw,<br>tt<br>d**ctrti*tla.**<br>et<br>.<br>19<br>.|
|**its**|**state**t**sum**<br>ZiSI<br>1c<br>r dI<br>.342<br>6.13<br>T<br>nd<br>1edthl.|la$ TeW<br>To<br>Oseo<br>&worm&|.<br>d||30.9<br>In thoryv<br>heal_th_**care to frle**for *11_Par_<br>In Z7bl.<br>_lut._employees**at**%._ZT_COlyMOCtWtlt**5.n**<br>t_"W_<br>i;etlUtle.<br>hut hwo 24.13_of_**Ise**d<br>story hIeth<br>lts<br>smtM<br>tha.<br>Sarae: RUB).: PapeLettin,NeltSnd11t1firittn**tStSr**dfdim.<br>MY.T91.|
|Zigbb|6iit.S<br>"a16ap(ewe<br>Priveto, 3164.60<br>4 <sup>.</sup>63<sup>b</sup><br>**100**<br>wTd<br>faditll.<br>Ao ot@tiSantource.<br>0lletmmt Asosciationat of Nale<br>AidSecttelte.<br>hioerpinimiet<br>**eae**otisiuot**ultIe**t.n cOs<br>S cas<br>OPl,e<br>384.050)ad_ta.)r_<br>etlyr<br>tfl<br>I tpremlu pid.<br>;y.cry.<br>reuired for BrUB.|**v"O**<br>**les**<br>Tog<br>**swamtya**<br>Zs**2?3c**<br>oim<br>totY|**wamI**<br>by<br>**se**<br>10T.|so|105.00 lnswratieSeemy s1Mdlzed by<br>datlhcttbilytU<br>**PmrI**<br>ofboth_ptoer<br>md npl<br>.<br>_2l_<br>_<br>1:<br>t<br>Isen<br>ti n<br>**a.**<br>r<br>**FiftMu**<br>**Of IeatS CAe.**<br>heat.<br>9.|
# PRE Working Paper Series

||_TiA_|Aeho||Contact<br>f|
|---|---|---|---|---|
|WPS455|A Formal Estimation of the Effect<br>of the MFA on Clothing Exports<br>from LDCs|Junichi Goto|June 1990|M. T. Sanchez<br>33731|
|WPS456|Improving the Supply and Use of<br>Essential Drugs in Sub-Saharan Afric|S. D. Foster<br>a|June 1990|Z. Vania<br>33664|
|WPS457|Financing Health Services in Africa:<br>An Assessment of Alternative<br>Approaches|Germano Mwabu|June 1990|Z. Vania<br>33664|
|WPS458|Does Japanese Direct Foreign<br>Investment Promote Japanese Impor<br>from Developing Countries?|Kenji Takeuchi<br>ts|June 1990|J. Epps<br>33710|
|WPS459|Policies for Economic Development|Stanley Fischer<br>Vinod Thomas|June 1990|WDR Office<br>31393|
|WPS460|Does Food Aid Depress Food<br>Production? The Disincentive<br>Dilemma in the African Context|Victor Lavy|July 1990|A. Murphy<br>33750|
|WPS461|Labor Market Participation, Returns<br>to Education, and Male-Female<br>Wage Differences in Peru|Shahidur R.<sup>Khandker</sup>|July 1990|B. Smith<br>35108|
|WPS462|An Alternative View of Tax<br>Incidence Analysis for Developing<br>Countries|Anwar Shah<br>John Whalley|July 1990|A. Bhalla<br>37699|
|WPS463|Redefining Government's Role in<br>Agriculture in the Nineties|Odin Knudsen<br>John Nash|August 1990|K. Cabana<br>37946|
|WPS464|Does A Woman's Education Affect<br>Her Husband's Earnings? Results<br>for Israel in A Dual Labor Market|Shoshana Neuman<br>Adrian Ziderman|August 1990|V. Charles<br>33651|
|WPS465|How Integrated Are Tropical Timber<br>Markets?|Panos Varangis|August 1990|D. Gustafson<br>33714|
|WPS466|Is There An intra-Household<br>Kuznets Curve?|Lawrence Haddad<br>Ravi Kanbur|August 1990|J. Sweeney<br>31021|
|WPS467|Structurai Adjustment and Living<br>Conditions in Developing Countries|Nanak Kakwani<br>Elene Makonnen<br>Jacques van der Gaag|August 1990|B. Rosa<br>33751|
|WPS468|Does the Structure of Production<br>Affect Demand for Schooling in Peru|Indermit Gill<br>?|August 1990|M. Abundo<br>36820|
# PRE Working Paper Series

||Dlie|Author||Contact<br>forgaper|
|---|---|---|---|---|
|WPS469|Modeling Economic Behavior in<br>Peru's Informal Urban Retail Sector|J. Barry Smith<br>Morton Stelcner|August 1990|M. Abundo<br>36820|
|WPS470|What Do Alternative Measures of<br>Comparative Advantage Reveal<br>About the Composition of Developing<br>Countries' Exports?|Alexander J. Yeats<br>|August 1990|J. Epps<br>33710|
|WPS471|The Determinants<br>of Farm<br>Investment and Residential<br>Construction in Post-Reform China|Gershon Feder<br>Lawrence J. Lau<br>Justin Lin<br>Xiaopeng Luo|August 1990|C. Spooner<br>30464|
|WPS472|Gains in the Education of Peruvian<br>Women, 1940 to 1980|Elizabeth M. King<br>Rosemary Bellew|August 1990|C. Cristobal<br>33640|
|WPS473|Adjustment, Investment, and the<br>Real Exchange Rate in Developing<br>Countries|Riccardo Faini<br>Jaime de Melo|August 1990|R. Sugui<br>37951|
|WPS474|Methods for Measuring the Effect<br>of Adjustment Policies on Income<br>Distribution|Anne Maasland|August 1990|P. Dixon<br>39175|
|WPS475|Does Divestiture Matter? A<br>Framework for Learning from Experie|Ahmed Galal<br>nce|August 1990|G. Orraca-Tetteh<br>37646|
|WPS476|Health Insurance in Sub-Saharan<br>Africa: A Survey and Analysis|Ronald J. Vogel|August 1990|K. Brown<br>35073|